Application For Admission

Christian Center Academy

1401 S. Mt.Vernon Ave.

Colton, Ca. 92324

1250 B Beaumont Ave.

Beaumont, CA 92223

Non-discriminatory policy: it is the policy and practice of this school in the admission of students not to discriminate on the basis of the applicant’s race, color, gender or nationality or ethnic origin. We do reserve the right to screen applicants on the basis of religious preference.

Students Information

Name in Full: __________________________________________________

Last First Middle

Address ______________________________ City _____________ Zip _____

Date of birth _____________ Age _____ Gender M/F Grade entering _____

Place of birth ____________________ Race/Ethnicity __________________

If the student is not living with both parents, please check applicable reason:

Father deceased ____ Mother deceased ____ Separated ____ Divorced ____

Other reason _________________________________________________

Academic Profile

Please indicate any other name the student has been known by _______________

Last/Current School name ________________________________ Grade ____

Schools mailing address ___________________________________________

City                                                                 State                                                                             Zip

Phone (_____) ___________________ Principal _______________________

Has the student had any disciplinary difficulty in school? Yes ___ No___

If yes, please explain:_____________________________________________

______________________________________________________________

Had the student ever been Expelled, Suspended or put on Probation through the courts? (explain)

Does student have any known physical, emotional, or learning disability? Yes / No

If yes, please explain _____________________________________________
______________________________________________________________
______________________________________________________________

Please list any helpful observations (i.e. honors, habits, etc.) _________________
______________________________________________________________
______________________________________________________________

Name of church that applicant attends ________________________________
Phone _____________________ Pastor _____________________________
Attend: Regularly Occasionally

General Information

How did you become aware of this school? ______________________________

Why do you wish your child to receive a Christian based learning center? _______

______________________________________________________________

Family Information

Father / Step Father / Guardian Mother / Step Mother / Guardian

____________________________ ____________________________

Address _____________________ Address _____________________

____________________________ ____________________________

Phone _______________________ Phone _______________________

E-mail _______________________ E-mail _______________________

Mailing Information

All correspondence, billings, reports, notices, are to be sent to:

Name _________________________________________________________

Address _______________________________________________________

Street                                     City                                  Zip