Agape Christian high school

Southern Illinois Regional Christian School

(An independent Christian interdenominational not-for-profit school)
5208 Meadowland Pkwy. #A, Marion, IL 62959 (618) 997-9302

Re-enrollment Application
Todays date: _____________
Student Information
*If your family is enrolling more than one student, please complete a separate application for each student.

Grade to Enter:

(circle one)

10

11

12

Students Name: ____________________________________________ Home phone #______________

Last

First

Middle

Nickname

Street Address: ________________________________ City or Township _________________Zip____

Cell phone #s: Students________________ Mothers________________ Fathers________________
Date of Birth:_________ Birthplace: City______________State___ Student S.S.#__________________
Gender and Age: Female ___Male ___
Family Information Student lives with:

Current age ____

____Father/Mother ____Mother
___StepMother/Father ___StepFather/Mother

____Father
___Guardian

Medications/Health Concerns:____________________________________________________________
Current Church and Pastor Name _________________________________________________________
Fathers Name _______________________
Address and home phone (if different than
student or mother)______________________
________________________cell # _________
Occupation: ____________________________
Employer: _____________________________
Business phone: _________________________
Marital status: __________________________

Mothers Name _____________________________

Address and home phone (if different than student or
father) _____________________________________
___________________________cell # ___________
Occupation: ________________________________
Employer: _________________________________
Business phone: _____________________________
Marital status: ______________________________

Family e-mail address: _________________________

(If student lives with a guardian, list name and address:_______________________________________)
Emergency Information

(in case parents cannot be contacted immediately)

_______________________________ ________________ ___________________________________

(Name)

(Phone #)

(Relationship to Student)

ACHS admits ninth through twelfth grade without regard to race, color, national or ethnic origin.

Parent/Student Covenant with ACHS

We (parents) and I (student) understand and covenant that this students attendance at ACHS signifies that we
collectively pledge to agreeably abide by all policies, requirements and rules set forth by the school as of now
and hereafter to be set by school board or administration policy.

____________________________

_____

Parents signatures

Date

_______________________________
Students signature

_________
Date