FOR OFFICE USE ONLY:

Student Name

Student #:

Family Mail List Ref #:

? NC ? SC ? DB ? ACT ? SF

Registration Fee Paid:

? Cash $_______ ? Check (No. _______ ) $_______ ? No

Material Fee Paid:

? Cash $_______ ? Check (No. _______ ) $_______ ? No

Champion Christian School

Application for Admission

Date of Application

Please correct errors and fill in any applicable blank spaces.

Student Information

Students Full Name
Grade Level Applying For			Date of Birth
Home Phone
Township of Residence			School District
County of Residence
If Transfer Student, List Previous School(s)
Name(s) of Parents, Legal Guardians, and Persons with whom student primarily resides	Name	v if child resides with this person	Relationship




Parent(s) Marital Status

Parent and/or Legal Guardian Information

This should be filled out by the persons who are legally responsible for the student and who have the right to sign legal documents on behalf of the student.

Mother/Stepmother's Information		Father/Stepfather's Information (if different from mother)
Address		Address
City/State/Zip		City/State/Zip
Home Phone		Home Phone
e-mail		e-mail
Cell Phone		Cell Phone
Employed By/ Occupation		Employed By/ Occupation
Work Address		Work Address
Work Phone		Work Phone
Usual Work Hours		Usual Work Hours

Primary Caretaker Information

This should be filled out by the persons with whom the student primarily resides (if residence is not primarily with the parents or legal guardians). These persons will be contacted with daily correspondence from the school.

Name & Relationship		Name & Relationship
Address		Address
City/State/Zip		City/State/Zip
Home Phone		Home Phone
e-mail		e-mail
Cell Phone		Cell Phone
Employed By/ Occupation		Employed By/ Occupation
Work Address		Work Address
Work Phone		Work Phone
Usual Work Hours		Usual Work Hours

List Siblings

Name	Date of Birth & Age	List Program(s) Sibling is Currently Enrolled in at CCS

Emergency Contact Information In case of an emergency, parents or guardians will be notified first. If unavailable, primary and secondary contacts will be called.

Name & Relationship		Name & Relationship
Address		Address
City/State/Zip		City/State/Zip
Home Phone		Home Phone
Cell Phone		Cell Phone
e-mail		e-mail
Work Phone		Work Phone

Student Contact Information

Student's Cell Phone

Student's

e-mail

Medical Information

Pediatrician or Family Doctor
Address
Telephone
Insurance Coverage ? YES ? NO Name of Company
Group & Policy Number
Hospital Preferred (if injury is not life threatening)
Allergies or Medical Information Needed pertaining to an Emergency
Does the school have permission to authorize emergency medical treatment?	? YES ? NO

Emergency Medical Care Consent

Written Consent is given for (check items for which you give your consent):

Emergency Medical Care (including application of antibiotic cream if needed)	? YES ? NO
Administration of Prescription Medications (when accompanied by specific permission form which also includes physician's written instructions)	? YES ? NO
Administration of Special Dental or Dietary Needs (please list all that can be administered, dosage, and methods)	? YES ? NO
Any Other Special Instructions or Care to be Administered by the Center (Please specify:)

Transportation Information

Bussing to Champion Christian School is available for students in K-12 who live within certain school districts. This information varies from year to year, and you will be notified by orientation about this option.
Directions to your home from a major highway or landmark. Please do not draw maps and be VERY specific:

Financial Aid Information

Financial Aid is available for students in Preschool-12 who meet income eligibility guidelines. If you need financial assistance with tuition please complete the financial aid forms and return them to the school.
Please place a check mark by the financial aid forms that you have completed and returned for the 2010-2011 year (including those that you will be returning along with this application)	? EITC ? CCS Financial Aid Application

Persons authorized to pick up student from school

Name	Relationship to Student

Other Information

Why do you want your child to attend Champion Christian School?

Are there any special needs your child has that the school needs to be aware of?

Is anyone in your family involved in any programs offered by the Center? _____ If yes, please list their name and the program(s) they are involved in below.

Preschool Only: Please indicate your program preference(s) by checking all programs you would be interested in, as we cannot guarantee placement in a specific program. Program offerings are dependent on the number of applications we receive.

Circle one: North Campus, Donegal or South Campus, Indian Head

? Two Day AM (T-TH) ? Two Day PM (T-TH) ? Three Day AM (MWF) ? Three Day PM (MWF)

Blanket Transportation Permission Form

I, ___________________________ , give permission for my child, ___________________________ , to attend local community activities such as walks to Resh's Park, the gym at the Indian Head Community Center, local churches, hikes, general community service and to be transported between North and South Campus for events sponsored by Champion Christian School.

_______________________________ / ____________________

(Parent's or Guardian's Signature) (Date)

Handbook and Enrollment Acknowledgment

I, ______________________, acknowledge that I am in receipt of the parent and student handbooks for my student's program. I also acknowledge that I have read/will read the parent and student handbooks and my child will abide by the guidelines set forth in them. I understand and agree that continued enrollment and re-enrollment of my children in Champion Christian School is dependent on my parental support of the school, its staff, and its policies. I understand that Champion Christian School has a rolling enrollment policy and that this application for CCS enrollment will be considered current and kept on file until my child is withdrawn.

______________________________ / _____________________

(Parent's or Guardian's Signature) (Date)

My signatures above verify that all the information contained

in this application is true and correct to the best of my knowledge.

Please complete, sign and mail (or bring) completed application to:

Champion Christian School, 2166 Indian Head Road, Champion, PA 15622