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Student Information

Student Name*

First Middle Last

Student Gender*

Grade applying for:*

Birthdate*

Month

Day

Year

Birth Certificate Upload

Drop files here or

Max. file size: 256 MB.

Please upload your child's birth certificate

Birthplace*

City State Country

Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone*

Cell Phone

Email Address*

Current School Now Attending*

Current Grade*

School Address*

Street Address City State ZIP / Postal Code

Baptism Date*

Month

Day

Year

Church Name

Family Information

Not applicable

Check here if not applicable (e.g. single parent)

Father's Name*

First Middle Last

Father's Birthplace*

Father's Religion*

Father's Occupation*

Father's Marital Status*

Is the last name different from the applicant's last name?*

Yes

If name is different from applicant's, what name is used?*

Not applicable

Check here if not applicable (e.g. single parent)

Mother's Name*

First Middle Maiden

Maiden Name

Mother's Birthplace*

Mother's Occupation*

Mother's Marital Status*

Is the last name different from the applicant's last name?*

Yes

If name is different from applicant's, what name is used?*

Are the child's parents divorced?*

Yes

If divorced, who has legal custody of the applicant*

Not applicable

Check here if not applicable (e.g. single parent)

Guardian's Name*

First Middle Last

Guardian's Birthplace*

Guardian's Occupation*

Guardian's Marital Status*

Is the last name different from the applicant's last name?*

Yes

If name is different from applicant's, what name is used?*

Parent/Guardian Questionnaire

Child Applicant's Name*

First Last

Nickname*

Entering Grade*

Birth Date*

Month

Day

Year

Present Age*

Previous School(s)

Previous School(s) attended.

Name of School

From

Month

Day

Year

Month

Day

Year

Name of School

From

Month

Day

Year

Month

Day

Year

Name of School

From

Month

Day

Year

Month

Day

Year

Upload 2 Years of Report Cards and Standardized Test Results

Please upload the last 2 years of the student's report cards and standardized testing.

Drop files here or

Max. file size: 256 MB.

Additional Students

Names and grades of other family children applying

Additional Student(s)

Name	Date of Birth	Entering Grade Level	Enrollment Fee	Actions

There are no Students.

Maximum number of students reached.

Please add any information that might be pertinent in helping us evaluate this application.*

How do you plan to contribute your time and talent to the school community?*

Family Education History

Not applicable

Check here if not applicable (e.g. single parent)

Father's Elementary School

Elementary School Address

City State

Father's High School

High School Address

City State

Father's College

College Address

City State

Not applicable

Check here if not applicable (e.g. single parent)

Mother's Elementary School

Elementary School Address

City State

Mother's High School

High School Address

City State

Mother's College

College Address

City State

Any other family background information that you would like to add

Payment Information

Application Fee

Price:

Application Fee Total

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code

Credit Card*

Card Details

Cardholder Name

Consent

I agree to the payment policy below.

I authorize the company named on this web form to debit the bank account or credit card indicated in this web form, for the noted amount on today's date. This payment is for the goods and services noted on the web payment form. I understand that returns, refunds and cancellations are not permitted, however exceptions may be made on a case-by-case basis. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. I agree that payments for billing schedules with common bill dates may be consolidated into a single payment. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that the company named on this web form may at its discretion attempt to process the charge again within 30 days. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card or bank account, and that I will not dispute the payment with my Credit Card Company or Bank, so long as the transaction corresponds to the terms indicated in this web form.

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Student Information

Family Information

Parent/Guardian Questionnaire

Previous School(s)

Additional Students

Family Education History

Payment Information

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UP Christian Academy

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