By submitting this application, you and your child agree to be considered
for enrollment at chooselife EDU Co-Op. chooselife EDU Co-Op
reserves the right to accept or reject any application.
Date:
-
Month
-
Day
Year
Date
CHILD & FAMILY INFORMATION
CHILD'S INFORMATION
Child's Name
First Name
Middle Initial
Last Name
Preferred Name:
Age:
Date of Birth:
-
Month
-
Day
Year
Date
Gender:
Male
Female
Current Grade Level:
T-Shirt Size (be specific):
Child's Address:
Attends chooselife CHURCH:
Yes
No
Number of services attended per month:
HEALTH INFORMATION
Allergies:
Medications:
Existing Illness:
Yes
No
If yes, explain:
Serious injury/illness in past 12 months:
Yes
No
If yes, explain:
Physician's Name:
Format: (000) 000-0000.
Address:
Hospital:
Format: (000) 000-0000.
Address:
PARENT/GUARDIAN INFORMATION
MOTHER / GUARDIAN
Mother/Guardian Name
First Name
Middle Initial
Last Name
Home Address:
Format: (000) 000-0000.
Mailing Address (if different):
Occupation:
Format: (000) 000-0000.
Employed By:
Format: (000) 000-0000.
Work Address:
Work Hours:
Driver's License #:
Email:
example@example.com
Marital Status:
Married
Single
Divorced
Separated
Widowed
Other
chooselife CHURCH Partner:
Yes
No
Number of services attended per month:
Power of Attorney:
Yes
No
*(If guardian, please attach a copy of Power of Attorney to this application.)
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FATHER / GUARDIAN
Name:
First Name
Middle Initial
Last Name
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Mailing Address (if different):
Occupation:
Cell Phone:
Format: (000) 000-0000.
Employed By:
Work Phone:
Format: (000) 000-0000.
Work Address:
Work Hours:
Driver's License #:
Email:
example@example.com
Marital Status:
Married
Single
Divorced
Separated
Widowed
Other
chooselife CHURCH Partner:
Yes
No
Number of services attended per month:
Power of Attorney:
Yes
No
*(If guardian, please attach a copy of Power of Attorney to this application.)
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CHILD'S EDUCATION BACKGROUND
*(Please fill out this section WITHOUT the aid of your student if possible.)
1. What kind of learner would most describe your student: (check the one that most applies):
Independent - works well alone and remains motivated
Group - prefers social learning environments to maintain motivation and focus
Mentored - requires one-on-one attention to remain motivated and
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 interest?
5. In which subject has your student demonstrated the least interest?
6. Describe how your student handled public school on a social level: (circle all that apply)
Works well with others
Little conflict
Some conflict
Lots of conflict
Fighting
7. Describe your student's relationship with teachers: (circle all that apply)
Little problems
Teacher's pet
Positive feedback
Negative feedback
Principal's office
8. What extracurricular activities does your student find most enjoyable?
9. Describe your student's attitude toward 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 most applies)
Leader
Attempts to lead
Isolated
Follows others
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12. What were your student’s grades the last semester of their last year of school:
Please fill out below.
1. Class:
Grade:
2. Class:
Grade:
3. Class:
Grade:
4. Class:
Grade:
5. Class:
Grade:
6. Class:
Grade:
7. Class:
Grade:
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.
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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?
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PERSONAL LIFE
1. How often have you received D-Hall/ Detention 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?
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SPIRITUAL LIFE
1. In what way have you grown spiritually this year?
What person did you have the most impact on spiritually this past year and why?
ADDITIONAL COMMENTS & INFORMATION
Are there any concerns you have about student participation in chooselife EDU Co-Op?
Is there any other information that would be helpful to our management and staff?
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TUITION / PAYMENT INFORMATION:
Hours: M-F 8:30 am - 3:30 pm
Tuition Payment Schedule:
Payments will be automatically deducted on the 1st of every month. Credit card must be on file, if payment is declined a $35.00 fee will be added each time declined. If payment is late an additional $35.00 fee will be added. Non-payment will result in dismissal.
Tuition rates and payment details will be provided upon acceptance and reviewed during the enrollment meeting.
Tuition is $300.00 monthly. $280 for each subsequent child.
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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 scholarship is available at time of submission. All information will
be kept confidential.
Mother/Guardian
Date
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Month
-
Day
Year
Date
Father/Guardian
Date
-
Month
-
Day
Year
Date
Thank You!
$50 NON-REFUNDABLE (CASH ONLY) APPLICATION FEE REQUIRED!
Applications are processed once the fee is received. Enrollment is first-come, first-served. Acceptance is
finalized after the interview.
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