CentralValleyChristianAcademy

2020 Academy Place • Ceres, CA 95307

(209) 537-4521  Fax (209) 538-0706

APPLICATIONGRADES K – 12

STUDENT INFORMATION (Please print using blue or black ink on all forms)

LEGAL NAME, LAST / FIRST / MIDDLE / Last grade completed
ADDRESS / CITY / STATE / ZIP / HOME PHONE
SOCIAL SECURITY NUMBER / AGE / BIRTHDATE / BIRTHPLACE / ETHNICITY (Optional) / SEX
CHURCH MEMBERSHIP(Denomination) / If Adventist, where is your membership? / Are you a baptized Adventist? (Circle One)
Yes (Date): No
May we publish the following in the student directory: (Circle)Your Address? Yes NoYour Phone? Yes No
FINANCIAL INFORMATIONPerson responsible for payment of your expenses / Send a copy of grades to the person listed below? YesNo
NAME / STREET ADDRESS
CITY, STATE, ZIP / RELATIONSHIP TO STUDENT / Drivers License NUMBER
PARENT/GUARDIAN INFORMATION
FATHER’S NAME / OCCUPATION / EMPLOYER / PHONE NUMBERS
WORK:
MAILING ADDRESS / CITY / STATE / ZIP / HOME:
EMAIL ADDRESS / CELL:
MARITAL STATUS: (Circle One)
Married Widowed Separated Divorced Remarried / CHURCH MEMBERSHIP (Denomination): / NAME OF CHURCH
MOTHER’S NAME / OCCUPATION / EMPLOYER / PHONE NUMBERS
WORK:
MAILING ADDRESS / CITY / STATE / ZIP / HOME:
EMAIL ADDRESS / CELL:
MARITAL STATUS: (Circle One)
Married Widowed Separated Divorced Remarried / CHURCH MEMBERSHIP (Denomination): / NAME OF CHURCH
If parents are divorced, please send a copy of grades to (Circle)
Father OnlyMother OnlyBoth / STUDENT LIVES WITH / LANGUAGE SPOKEN AT HOME
MEDICAL INFORMATION / STUDENT’S PHYSICIAN NAME:
ADDRESS / CITY / STATE / ZIP / PHONE
EMERGENCY CONTACT (Other than parents) / RELATIONSHIP TO STUDENT / HOME PHONE / WORK PHONE
ADDRESS / CITY / STATE / ZIP / EMPLOYER
Have you used any tobacco, drugs, or intoxicating beverages within the last 6 months? Yes No If yes, please explain on back
NEW STUDENT INFORMATION / Do you have an unpaid school account? (Circle One) YesNo / If yes, how much? / Where?
REFERENCE: Name and address of one adult, other than a relative, with whom you are personally acquainted: (Such as principal, pastor or other) / TITLE
PHONE:
EDUCATION: Name and address of school you previously attended: / YEAR
Have you been dismissed from school within the last year? (Circle One) Yes No If Yes, explain where and why:
Student pledge: I am in full harmony with the regulations and principles laid down for the government of the Academy and as stated in the school handbook. If accepted, I hereby agree to obey the regulations of the school, to pay my bills promptly, work where I am assigned, and to cooperate cheerfully and whole-heartedly in upholding the standards of the school
Student signatureDate / Contract of parent/guardian: I have read the answers to the above questions, and find they are correct. I agree to the conditions herein stated, and I am in harmony with the regulations and policies of the Academy as stated in the school handbook, or as shall be announced by the principal and manager during the year, and I agree to assume the financial responsibility for the above student.
Parent/Guardian signatureDate

The following additional forms must be included with the application: • Birth Certificate for all Kindergarten and 1stgrade students

• Emergency Consent to Treatment

• Report of Health Examination/Student Medical Record forstudents

entering school for the first time and those entering grades, 7th, and 9th

• Current Immunization record

• Transcript of record and/or most recent grade report and standardized test results fromprevious school

• Financial Policies and Procedures

• Letter of Recommendation for students entering grades 5-12