ReApplication for Existing Students

Middletown Christian School

REAPPLICATION
70 Highland Avenue Middletown, NY 10940 Phone: (845) 343-3775 Fax: (845) 343-6633
STUDENT INFORMATION
FIRST NAME
MIDDLE NAME
LAST NAME
DATE OF APPLICATION

MonthDayYear
Date
STREET ADDRESS
CITY
STATE
ZIP
HOME PHONE
STUDENT'S AGE
Gender
BIRTHDATE

MonthDayYear
Date
BIRTHPLACE
GRADE NEXT SCHOOL YEAR
CHURCH AFFILIATION
DATE BAPTIZED

MonthDayYear
Date
PARENT'S E-MAIL ADDRESS
example@example.com
IN CASE OF EMERGENCY CALL:
NAME
PHONE
CELL PHONE
STUDENT'S SOCIAL SECURITY NUMBER
SCHOOL DISTRICT IN WHICH STUDENT IS LIVING
WE UNDERSTAND THE OBJECTIVES AND REGULATIONS OF THE SCHOOL AND PLEDGE OUR FULL SUPPORT.
PARENT'S SIGNATURE

Clear
Should be Empty:

Middletown Christian School