Registration

R. A. Hudson Christian Academy of Mastery Learning

2709 North 19th Street Hueytown, AL 35023

(205) 491-3884

Board of Directors

Bishop Rochelle A. Hudson, President

Elder Bessie Dunn, Principal

Nicoa Hamilton, Secretary

Annette Brown, Bookkeeper

Erma Hudson, Chaplain

Fredrick Thomas

STUDENT APPLICATION

REGISTRATION FEE:$60.00 for one child $50.00 each for two or more children

Application Date______

STUDENT INFORMATION

Full Name______Age______Sex______

Address______City______State______Zip ______

Home Telephone ______Social Security Number ______

Date of Birth ______/______/______BirthPlace______

School Last Attended______Address______Last Grade Completed______

FOR SEVERE WEATHER OR IN CASE OF EMERGENCY, THE FOLLOWING INFORMATION MUST BE UPDATED AS IT CHANGES.

FAMILY INFORMATION

Father’s Name ______Employment ______

Position ______Work Phone Number ______

Mother’s Name ______Employment ______

Position ______Work Phone Number ______

Emergency Phone Number ______Person’s Name ______

With whom does the student live? ______

Other siblings in family ______

Will any of these siblings be applying? ______

Registration

RELIGIOUS INFORMATION

Church Membership ______Address______

Phone Number ______Pastor______

Church Activities ______

MEDICAL INFORMATION

Family Physician ______Phone Number ______

Does the student have any physical impairments or allergies?______

______

Does student take any prescription medicine(s)? ______

Is the student’s immunization record up to date? ______

ADDITIONAL MEDICAL INFORMATION

Full Name______Age______

Sex______

Other information that may be pertinent to the school:

(i.e., seizures, food allergies, asthma, allergic reactions, etc.)

______

______

Registration

STUDENT APPLICATION

This application must be filled out completely before it can be processed. Once you complete the application, you may bring it to the school, along with a registration fee of $60.00 (cash, money order or cashier’s check only, no personal checks). Upon receipt of the application and registration fee, an interview will be scheduled with parents/guardians and the student(s).

R. A. Hudson Christian Academy has a racial nondiscriminatory policy and, therefore, does not discriminate against members, applicants, students, and others on the basis of race, color, national or ethnic origin.

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Signature of FatherSignature of Mother

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Signature of GuardianSignature of Guardian

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Signature of School Official Title/Position

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Date