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Student Name

Select One Male Female

SSN

Birthdate

Age

Student is a U.S. Citizen Yes No

Race/Ethnicity

Student Batism Date

Address

Phone

Include Contact Information in School Directory Yes No

Parent/Guardian #1

Name

Marital Status

Relationship to Student

Address

Phone

Email

Employer

Occupation

Current Church Membership

Baptized Adventist Yes No

Parent/Guardian #2

Name

Marital Status

Relationship to Student

Address

Phone

Email

Employer

Occupation

Current Church Membership

Baptized Adventist Yes No

Student Health Information

Pediatrician Name

Pediatrician Phone

Allergies

Medical Conditions

Current Medications

Emergency Contacts

Select Parent/Guardian #1 Parent/Guardian #2 Other* Please Fill Form Below

Name

Phone

Relationship to Student

Benefits of Multi-Grade Classrooms