Christian Life Academy-Student Application
Student name
First Name
Last Name
Parent Email
example@example.com
Parent/Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Parent/Guardian relationship to Student
Father
Mother
Other
Does Student live at Parent/Guardian residence?
yes
no
Student Date of Birth
Last School Attended
Student Gender
male
female
Student Ethnicity
White
Hispanic
Black
American Indian
Asian
Other
Last Grade Completed
Student Social Security Number
List any academic concerns you have for this student
List any medical issues CLA should be aware of.
Parent/Guardian Name
First Name
Last Name
Physician Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Relationship to Student
Mother
Father
Grandmother/father
Family Friend
Other
Emergency Contact Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: