ACTS CHRISTIAN ACADEMY
2600 N SULLIVAN AVE
FARMINGTON, NM 87401
(505) 325-2600
School Year: ___________ Grade Applying For: ____________
Student Information: SS# ___________________
Name (First, Middle, Last) _________________________________________________
Male ____ Female ____ Date of Birth ____________ Age ____ Race ______________
Street Address ___________________________________________________________
Mailing address (if different) ________________________________________________
Home Phone ___________________________ Alternate Phone ____________________
Parent/Guardian Information:
Father’s Name ________________________________Child lives with? Yes or No (circle)
Employer ____________________________ Work Phone ________________________
Cell Phone __________________ Home phone (if different from student) _______________
Mother’s Name _______________________________Child lives with? Yes or No (circle)
Employer ____________________________ Work Phone ________________________
Cell Phone __________________ Home phone (if different from student) _______________
Marital Status: Married ___ Divorced ___ Separated ___ Single ___ Widowed ___
Name of Home Church ____________________________________________________
Address __________________________________ Phone ________________________
Pastor’s Name ___________________________________
Regular attendance _____ Occasional attendance ____ Seldom attend _____
Are you involved in Christian worship, study, services, etc..? ______________________
________________________________________________________________________
Family Information:
Siblings:
Name/Age ________________________ Name/Age __________________________
Name/Age ________________________ Name/Age __________________________
Name/Age ________________________ Name/Age __________________________
Educational Information:
Please list schools previously attended beginning with the most recent:
School Address City, State, Zip Grades Completed
________________________________________________________________________
________________________________________________________________________
Has the student ever been held back a grade? Yes or No (circle) If yes, please explain:
________________________________________________________________________
________________________________________________________________________
Has the student ever been suspended, expelled, or been asked to withdraw from any previous school? If yes please explain: ________________________________________
________________________________________________________________________
Student Release Information:
It is necessary that students are released to authorized persons only. Please list person authorized to pick up your child from school. The list should include parents, guardians, relatives, and caregivers. Students will be released ONLY to persons listed below unless written notification is made in advance. Persons not known to ACA staff members will be asked to present identification. Please make individuals picking up your child, aware of the procedures. Notify the school office if any changes should be made to this list.
Name Relation Phone #
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Personal Information:
How did you hear about Acts Christian Academy? ______________________________
________________________________________________________________________
What is your specific purpose for enrolling your child at Acts Christian Academy?
________________________________________________________________________
________________________________________________________________________
What are your goals for your child? __________________________________________
________________________________________________________________________
Acts Christian Academy admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national, and ethnic origin in administration of its educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs.
I / We, state the information provided for registration purposes is true to the best of our knowledge.
_________________________________ ______________
Parent/Guardian Signature Date
_________________________________ ______________
Parent/Guardian Signature Date
Student Name ______________________________________
