East Los Angeles Light & Life Christian School
Application for Admittance
This application
does not secure enrollment, but provides information upon which we can base
a decision which will be in your child’s best interest. Testing fees
are due on the test date and are not refundable. A non-refundable
registration fee is due upon notification that your child has been accepted
to East Los Angeles Light & Life Christian School. Your child’s place
will not be reserved until all registration forms are complete, registration
fees are paid in-full and *financial contract is signed. (*Make an
appointment with the Financial Office)
STUDENT
INFORMATION
Application for Enrollment in
Grade__________
Date______/______/______
Student’s Full
Legal
Name_____________________________________________________________________________
Last
First
Middle
____________________________________________________________________________________
Address
City
Zip
Home Phone (_______)
________-____________
Student’s Social Security
Number________-______-________
Date of
Birth________/________/________
Age__________
Gender__________
Place of
Birth_______________________________________________________________________________________
City
State
Country
SCHOOL
INFORMATION & STUDENT BACKGROUND
School last attended (or currently
attending) _______________________________________________________________
__________________________________________________________________________________________________
Address
City
State
Zip
Phone (_______) ________-____________
Grade last enrolled __________
Status:
_____passed
_____retained
_____double promoted
_____passed on condition (state condition)
__________________________________________________
Was the student ever dismissed from a
school or asked not to return? ___Yes ___No
If yes, explain:
______________________________________________________________________________________
Was the student ever tested for
behavior, emotional or learning disabilities? ___Yes ___No
If yes, explain:
______________________________________________________________________________________
As parent/guardian
of the above named child, I acknowledge the importance of full disclosure,
including but not limited to any
behavioral,
emotional or learning disabilities. To the best of my knowledge the
School Information & Student Background Information
disclosed above
is accurate and true.
_____________________________________
*_____________________________________
____/____/____
Name of
Parent/Guardian (please print)
Signature of Parent/Guardian
Date
FAMILY
INFORMATION
Father’s Name______________________________________________________________________________________
Last
First
Middle
____________________________________________________________________________________
Address
City
State
Zip
Home Phone (_______)
________-____________
E-mail: _______________________________________
Place of
Employment_____________________________________ Occupation
__________________________________
____________________________________________________________________________________
Business Address
City
State
Zip
Business Phone (_______)
________-____________
Mother’s Name_____________________________________________________________________________________
Last
First
Middle
____________________________________________________________________________________
Address
City
State
Zip
Home Phone (_______)
________-____________
E-mail: _______________________________________
Place of
Employment_____________________________________ Occupation
__________________________________
____________________________________________________________________________________
Business Address
City
State
Zip
Business Phone (_______)
________-____________
LEGAL
GUARDIAN (if other than
parents):
Legal
Guardian’s Name______________________________________________________________________________
Last
First
Middle
____________________________________________________________________________________
Address
City
State
Zip
Home Phone (_______)
________-____________
E-mail: _______________________________________
Place of
Employment_____________________________________ Occupation
__________________________________
____________________________________________________________________________________
Business Address
City
State
Zip
Business Phone (_______)
________-____________
BROTHERS AND SISTERS
(list below)
Name
Age School Presently Attending
______________________________
__________
____________________________________
______________________________
__________
____________________________________
______________________________
__________
____________________________________
Is there a court order in effect
that relates to the student?
___Yes ___No
Effective Date _____/_____/_____ Type of Court Order:
____________________________________
Person(s) Restricted
_________________________________________________________________________
(Note: East Los Angeles Light & Life Christian School requires copies
of all court orders prior to enforcement.)
If parents are divorced, who has
legal custody of the child?
__________________________________________________
East Los Angeles Light & Life Christian School
Health Information
Date______/______/______
Student’s
Name_____________________________________________________________________________________
Last
First
Middle
MEDICATION INFORMATION:
East Los
Angeles Light & Life Christian School is not authorized to administer any
medications to students (over-the-counter and/or prescription medications)
without the written consent of a students student’s parent/legal guardian.
Please come to the school office and fill out a medication permission form
if your child requires any medications.
I give permission for the
administrative staff to administer Acetaminophen (generic Tylenol) at any
time to the above named
student (select one)
□
Child dose (160mg)
□
Junior dose (250mg)
□
Adult dose (500mg)
Parent Signature
__________________________________________
Date ______/______/______
Insurance
Provider: ____________________________________
Policy #: _______________________________
Doctor’s Name:
_______________________________________
Phone: (_______) _______-________________
Does the student have a history of:
(check all that apply)
___Frequent colds
___Frequent sore throat
___Bronchitis
___Hearing deficiency
___Vision
deficiency
___Allergies
___Asthma
___Seizures
___Other
__________________________________________________________________________________________
Does the student wear glasses?
___yes ___No If yes,
when? _________________________________________
Specify any hearing/vision
deficiencies:
__________________________________________________________________
__________________________________________________________________________________________________
Specify any allergies:
________________________________________________________________________________
Is the student currently taking any
regular medication(s)? ___yes ___no
If yes, please explain:
________________________________________________________________________________
Medical History
Diseases
(indicate date diagnosed)
Chicken Pox
____/____/____
Scarlet Fever ____/____/____
Rheumatic Fever ____/____/____
Diphtheria ____/____/____
Tuberculosis ____/____/____
Pneumonia ____/____/____
Diabetes ____/____/____
Polio ____/____/____
Mumps ____/____/____
Measles 3-day
____/____/____
Measles 10-day ____/____/____
Hepatitis “B” ____/____/____
Other:
____________________________________________________________________________________________
Has the student
had any operations? ___yes ___no
If yes, please indicate the procedure, date & results:
__________________________________________________________________________________________________
Is there any
reason why the student cannot participate in a full physical education
program? ___yes ___no
If yes, please
explain:
________________________________________________________________________________
If you have
additional notes regarding student’s medical history, please explain here:
______________________________
__________________________________________________________________________________________________
As parent/guardian
of the above named child, I acknowledge the importance of full disclosure of
my child’s health information. To the best of my knowledge the medical
information I have provided above is accurate and true.
_____________________________________
*_____________________________________
____/____/____
Name of
Parent/Guardian (please print)
Signature of Parent/Guardian
Date
