Current Student's Information

Student's Full Name*
Date of Birth*
Place of Birth*
Gender*
Social Security Number*
Home Address*
City, State, Zip*
Phone*
Grade Entering*
Current Grade*

Father’s (or Male Guardian’s) Information)

Father’s (or Male Guardian’s) Full Name*
Occupation*
Employer*
Work Address*
City, State, Zip*
Work Phone*
Cell Phone*
Primary Email*

Mother’s (or Male Guardian’s) Information)

Mother’s (or Male Guardian’s) Full Name*
Occupation*
Employer*
Work Address*
City, State, Zip*
Work Phone*
Cell Phone*
Primary Email*

Family Information

Family Status*
If the child is not living with both parents, please explain.*
Names of siblings attending Liberty Christian School:*

Emergency Contact Information

Name of Emergency Contact (Other Than Parent)*
Emergency Contact’s Phone Number*

Church Information

Church Affiliation*
Do you attend church regularly?*
YesNo
Have the following been saved and baptized? Please check if yes.*
Father (or Male Guardian)Mother (or Female Guardian)StudentNone have been saved and baptized.

Student History

Has the student ever been expelled?*
YesNo
Has the student ever been retained? If yes, please indicate which grade below.*
Last School Attended*
School Address*
City, State, Zip*
Grade Last Year*
Has the student ever attended Liberty Christian School?*
YesNo
If the student has had any academic difficulties in school thus far, please explain.*
Condition of Health *
If you answered ‘Physical Disabilities’ above, please explain.
Has the student ever had any incidents with the law, or does he have a police record?*
YesNo
If you answered ‘Yes’ above, please explain.
Is the student a United States citizen? *
YesNo
Please state the reasons why you wish for this student to attend Liberty Christian Schools.*