chooselife EDU Enrollment Application

By returning this application you are requesting that your student be considered for enrollment into chooselife EDU Co-Op
Date*

MonthDayYear
Date
Parent/Guardian Information

Mother/Guardian
Name:*

First NameMiddle NameLast Name
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from Home Address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:*
Cell Phone:*
Employed By:*
Work Phone:*
Work Address:*
Work Hours:*
Custodial Parent (If married mark both parents) Mother's Drivers License:*
Email:*
example@example.com
Marital Status:*

MarriedSingleDivorcedSeparatedWidowedOther
chooselife CHURCH Partner:*

YesNo
Number of services attended per month:*
If guardian, do you have Power of Attorney over this child?*

YesNo
Please upload a copy of the Power of Attorney here.

Cancelof
Father/Guardian
Name:*

First NameMiddle NameLast Name
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from Home Address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:*
Cell Phone:*
Employed By:*
Work Phone:*
Work Address:*
Work Hours:*
Custodial Parent (If married mark both parents) Father's Drivers License:*
Email:*
example@example.com
Marital Status:*

MarriedSingleDivorcedSeparatedWidowedOther
chooselife CHURCH Partner:*

YesNo
Number of services attended per month:*
If guardian, do you have Power of Attorney over this child?*

YesNo
Please upload a copy of the Power of Attorney here.

Cancelof
Child's Infromation
Name:*

First NameMiddle NameLast Name
Name child prefers to be called:*
Age:*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:*

MaleFemale
Date of Birth:*

MonthDayYear
Date
Current Grade Level:*
T-Shirt size (Be very specific i.e. adult medium, kids 5-6, etc.)*
Number of services attended per month:

List any existing medical conditions, medication, and/or special attention your child may require. Allergies:
Attends chooselife CHURCH:*

YesNo
Number of services attended per month:*
Health

List any existing conditions, medication, and/or special attention your child may require.
Allergies:*
Medications:*
Serious injury or illness in the past 12 months? Yes
Existing Illness:*

YesNo
If yes, explain:*
Serious injury or illness in past 12 months?*

YesNo
If yes, explain:*
Physician's Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Hospital:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Education Background
1. What kind of learner would most describe your student: (select the one that most applies)*

Independent – works well alone and remains motivatedGroup - prefers social learning environments to maintain motivation and focusMentored – requires one-on-one attention to remain motivated and focused
2. In which subject has your student shown the most success?*
3. In which subject has your student shown the least success?*
4. In which subject has your student demonstrated the most success?*
5. In which subject has your student demonstrated the least success?*
6. Describe how your student handled public school on a social level: (select all that apply)*

Works well with othersLittle to no conflictSome conflictLots of conflictsFighting
7. Describe your student's relationship with teachers: (select all that apply)*

Little to no conflictTeacher’s petNothing but positive feedbackLots of negative feedbackLots of time in the principal’s office
8. What extracurricular subjects does your student find most enjoyable?*
9. Describe your student’s attitude towards school and education:*
10. Describe your weekly involvement in your student’s education on a typical week (For example, how much time do you spend working with your student, doing homework, talking about school, etc.): *
11. Where does your student appear to find themselves in settings with other students: (check the one that mostapplies)*

The LeaderMakes some attempts to leadIsolatedFollows other's lead
12. What were your student's grades the last semester of school:
13. Describe the consensus that was achieved during the combination of all the teacher/parent conferences you have had in your student’s learning history: *
14. Why do you believe chooselife EDU Co-Op is a fit for your student at this time?*
15. How has your student responded to the potential change in their education? Are they excited, frustrated, etc.*
chooselife CHURCH Background

Please either have your student fill this section out or fill it out WITH your student.
1. Who is your closest friend at church and why?*
2. How often do you attend church and why?*
3. What is one thing you have learned this past year at church that has really impacted you?*
Personal Life
1. How often have you received D-Hall in this past year and for what reasons?*
2. How many times have you received an F on your report card this past school year and for what reason?*
3. How many times have you been grounded or what has been the primary reason for being spanked?*
Spiritual Life
1. In what way have you grown spiritually this year?*
2. What person did you have the most impact on spiritually this past year and why? *
Additional Comments & Information
1. Are there any concerns you have about student participation in chooselife EDU Co-Op? *
2. Is there any other information that would be helpful to our management and staff?*
Tuition / Payment Information:

Hours: M-F; 8:30 a.m. – 3:30 p.m.

Tuition Payment Schedule:
- Payments will be automatically deducted on the 1st of every month. A credit card must be on file; if payment is declined, a $35.00 fee will be added each time it is declined. If payment is late, an additional $35.00 fee will be added. Non-payment will result in dismissal.
- Tuition is $200.00 monthly for the first child. $180.00 for each subsequent child.
Signature

I understand that all the above information will only be used to access my student for enrollment in chooselife EDU Co-Op and does not guarantee that a position is available at time of submission. All information will be kept confidential.
Mother/Guardian:*

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Date*

MonthDayYear
Date
Father/Guardian:*

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Date*

MonthDayYear
Date
A $50.00 (NON-REFUNDABLE) CASH ONLY administrative fee must accompany this application!

Acceptance upon interviews
Should be Empty:

Parent/Guardian Information

Father/Guardian

Child's Infromation

Health

Education Background

chooselife CHURCH Background

Personal Life

Spiritual Life

Additional Comments & Information

Tuition / Payment Information:

Signature