CCS Admissions Forms

Application for Admission

Last updated: July 2026
We are excited that you are applying to Centerville Christian School! We offer classes for students in grades K-8.

Please complete the following forms to apply for admission to CCS. Click next at the bottom of the page to proceed to the next form. Each form must be filled out separately for each student applying for admission, with the exception of the Financial Agreement. The Financial Agreement form only needs to be filled out once, as long as all children applying are listed.

We will review your application after submission and contact you soon thereafter.
- School Year
- Student Name
  
  First NameMiddle NameLast Name
- Preferred Name
- Gender
- Date of Birth
  
  MonthDayYear
- Grade Level
  Expected grade level of the student when they begin enrollment
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Primary Parent/Guardian (to be contacted first)
  
  PrefixFirst NameMiddle NameLast Name
- Home Address (if different from applicant)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Cell Phone Number
  
  Area CodePhone Number
- Home Phone Number
  
  Area CodePhone Number
- Email
  example@example.com
- Secondary Parent/Guardian (to be contacted second)
  
  PrefixFirst NameLast Name
- Home Address (if different from applicant)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Cell Phone Number
  
  Area CodePhone Number
- Home Phone Number
  
  Area CodePhone Number
- Email
  example@example.com
- Emergency Contact Name
  
  PrefixFirst NameMiddle NameLast Name
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Home Phone Number
  
  Area CodePhone Number
- Cell Phone Number
  
  Area CodePhone Number
- If your child has or you suspect any learning disabilities, please explain and include a copy of all testing that has been done.
- If your child has ever failed a grade in school, been expelled, or been refused admission to another school please explain.
- List any medical conditions, special dietary needs, medications, or allergies your child has.
- How did you find out about Centerville Christian School?
- I understand that any payments are payable to Centerville Christian School, located at 1010 Lower Shipps Bend Road, Centerville, TN 37033.
- I certify that the information provided on this application is accurate and complete.
- I understand that Centerville Christian School only admits students for whom we have the educational resources to meet, and that the school does not discriminate in admissions on the basis of gender, race, color, religion, or national origin.
- I understand that submission of this application does not constitute admission to Centerville Christian School.
- Parent/Guardian Signature
- Date
  
  MonthDayYear
- Second Parent/Guardian Signature (if applicable)
- Date
  
  MonthDayYear

School Record Release

Last updated: July 2025
In order to request school records from other schools, Centerville Christian School is required to obtain your written permission.
- Student Name
  
  First NameLast Name
- Date of Birth
- School Name
  Name of the school holding the applicant's records
- School Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- I hereby consent to the release of a copy of all records, which would include attendance records, transcripts, test results, IEP's, health and immunization records, grades to date of withdrawal, and any other information that might assist in placement and guidance.
- I understand that, pursuant to rights contained in the Family Education Rights and Privacy Act of 1974 any information released to Centerville Christian School will not be released to any other party without the written consent of the parents of the above named student, or the student if eighteen years of age.
- I understand that by completing the information my child's records will be released to Centerville Christian School.
- Signature
- Date
  
  MonthDayYear

Medical Information

Last updated: July 2025
This form helps us to ensure your child receives appropriate care in your absence if neither you nor your emergency contact can be reached.
- Student Name
  
  First NameMiddle NameLast Name
- Date of Birth
  
  MonthDayYear
- Allergies
  List all allergies including food, drug, environmental, insect, etc. Indicate "none" if applicant has no known allergies.
- Medications
  List all medications the applicant is currently taking.
- Parent/Guardian Name
- Home Phone Number
  
  Area CodePhone Number
- Work Phone Number
  
  Area CodePhone Number
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Work Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Insurance Provider
- Name of Policy Holder
- Family Doctor
- Family Doctor Phone Number
  
  Area CodePhone Number
- Family Doctor Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Please indicate if your child has received the following immunizations by recording a date. If your child has not been immunized for that disease leave the date blank. If you have chosen not to immunize your student, please sign the "Immunization Religious Exemption Form" below.
- Hepatitis
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Tetanus
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Polio
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Tetanus
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Diphtheria
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Pertussis
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- HiB
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- MMR
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Instructions to Parents/Guardians
  
  Vaccine preventable diseases continue to exist. Immunizations are one of the most cost effective measures to protect children, adolescents, and adults from harmful vaccine preventable diseases and possible death. A high proportion of children and adolescents must be immunized to prevent outbreaks of disease in school settings and other places where children and adolescents are educated, work, and play close together. A parent or guardian wishing to exempt their child from some or all vaccinations must provide a written statement indicating the religious objections to the vaccination(s). A person who has been exempted from a vaccination is considered susceptible to the disease or diseases for which the vaccination offers protection. This person may be subject to exclusion from school, group facilities or other programs, if the local and/or state public health authority advises exclusion as a disease control measure. By signing this religious exemption form, I acknowledge that I have been educated and received materials regarding the benefits of vaccination. I have had an opportunity to ask questions which were answered to my satisfaction. I further acknowledge that I may be placing myself or my child and others at risk of serious illness should my child contract a disease that could have been prevented through proper vaccination. I feel I understand the risks associated with not receiving the vaccines checked below. I also give permission to share my immunization record and /or Certificate of Religious Exemption with facilities or institutions, which are required by law to have such records and with my other health care provider(s).
- By signing my name below, I am attesting that I object to having my child immunized.
- Date
  
  MonthDayYear
- It is further understood that this consent is given in advance of any specific diagnosis, treatment or hospital care which might be required, but is given to provide authority to the treatment or hospital care which might be required, but is given to provide authority to Centerville Christian School or the physician to exercise their best judgment as to the requirements of such diagnosis and treatment. It is further understood that reasonable effort be made to contact parents/guardians or emergency contact prior to using this consent.
- I understand that as the parent or legal guardian I am responsible any fees incurred not covered by insurance.
- I/we hereby authorize any hospital, physician, or other person who has attended or examined the minor to furnish to the General Conference Insurance Service, or its representative, any and all information with respect to any illness, medical history, consultation, prescriptions or treatments, and copies of all hospital or medical records. A photostatic copy of this authorization shall be considered as effective and valid as the original.
- I/we hereby authorize any hospital or physician which has provided treatment to the above named minor to surrender physician custody of such minor to the above agent upon completion of treatment.
- By signing my name below, I am stating that I agree with the terms of this Consent to Treat form.
- Date
  
  MonthDayYear

Handbook Agreement

Last updated: July 2025
By signing your names below, you and your student are attesting that you have received and read the Centerville Christian School Handbook including the Computer Network Policy and agree to follow the policies outlined therein.
- Student Name
  
  First NameLast Name
- Student Signature
- Parent/Guardian Name
  
  First NameLast Name
- Parent/Guardian Signature
- Date
  
  MonthDayYear

Photo Release

Last updated: July 2025
This form is where you can indicate your preferences for how pictures, video, or audio of your child are shared.
- Child's Name
  
  First NameLast Name
- During school-related events including homeschool days, photo opportunities arise. We would like permission to use the photographs, audios, and videos taken during these events to post internally at the school such as in slide shows and newsletter.
  
  We would also like to use these resources for publicity purposes. We promote our school using brochures, websites, social media, and other promotional methods. When photographs, audios, and videos are used for publicity purposes, students will never be identified by name.
  
  CCS is a part of the KYTN Conference of SDA. At times, they will visit the school and take pictures for publicity purposes. Again, students will not be identified by name.
  
  Please indicate your preferences below.
- Do you give CCS permission to use photos, audios, and videos of your student for internal use?
- Do you give KY-TN Conference of SDA permission to use photos, audios, and videos of your student as stated above?
- Signature
- Date
  
  MonthDayYear

Transportation Permission

Last updated: July 2025
- Student Name
  
  First NameLast Name
- Primary Authorized Individual(s)
  List the first and last names of the primary individual(s) who be picking up your student from school.
- Additional Authorized Individual(s)
  List the first and last names of all other individuals (if any) who have your permission to pick up your student from school.
- By signing my name below, I consent to allow the above individuals to pick up my children from Centerville Christian School. I recognize that this permission will stand unless I revoke it by phone or in person.
- Date
  
  MonthDayYear

Cyclist & Pedestrian Waiver of Liability

Last updated: July 2025
As a parent/guardian of a student who will be biking or walking to and from school, I understand and accept all responsibilty for my child(ren)'s welfare while in transit to and from school whether traveling by bicycle or on foot.

I agree to hold harmless Centerville Christian School should any harm befall my child(ren) while they are walking or riding a bike to and from school.
- Student Name
  
  First NameLast Name
- My student may bike to and from school, even if I am not present.
- My student may walk to and from school, even if I am not present.
- Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate

Power Tool Usage

Last updated: July 2025
At times, our students will have the opportunity to participate in hands-on projects that involve the use of power tools (excluding power saws). These activities are designed to enhance their practical skills and understanding of various subjects.

Safety is our top priority. Students will receive thorough instruction on the proper use of power tools and the necessary safety procedures. Students will also be supervised at all times by qualified staff members during these activities.
- Student Name
  
  First NameLast Name
- Do you give the above student permission to use power tools under the supervision of the staff at Centerville Christian School?
- Parent/Guardian Signature
- Date
  
  MonthDayYear
- Should be Empty:

Application for Admission

School Record Release

Medical Information

Instructions to Parents/Guardians

Handbook Agreement

Photo Release

Transportation Permission

Cyclist & Pedestrian Waiver of Liability

Power Tool Usage