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New Student Info Record

* indicates a required answer.

1. *

Parent's Name and email address

2. *

Student's Last Name:

3. *

Student's First Name:

4. *

Student's current age and grade

5. *

Church Affiliation:

6. *

Name of your Pastor:

7. 

School:

Years:

Phone Number:

8. *

So that we may better serve your child, does your child have any learning disabilities or dyslexia?

If yes, please explain.

9.*

Will your child be attending public school or receiving auxillary services (Speech Therapy, etc. from the public school  at any time this year?

 (1 required)
Yes No
10. 

If so, how many hours/classes? 

Please explain:

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