Kingdom Christian

School
Registration Form
2012-2013
Grade:_________________
Teacher:_______________
Room #:_______________
Date Entered:___________
Registration Fee of
$125.00:__________________
Student Information:
Students Name: __________________________________________________
Preferred Name: __________________________________________________
DOB: _____________________ Age______M/F ______ SSN#: ________________________
Allergies/Health:
Issues:
Florida Certification of Immunization, State Birth Certificate, and Student Health Form required for all students.
Address Line 1: _______________________________________________________________________
_______________________________________________________________________
City
State
Zip Code
County
Home Phone #1:
Home Phone #2:

Transportation:
How will the student be arriving to and departing from school? ___________________________________

Educational Background:
Does your child have any special needs? (Academic, Behavior, and Medical)Explain._______________________
Does your child receive any special services? ( Special Education, IEP, 504 plans, and Speech)
_______________________________________________________________________________________ _
Has your child been diagnosed with any learning disabilities by a licensed physician, psychologist or other doctor?
Explain.
__________________________________________________________________________________________
Does your child take or has ever taken any medicine to treat any learning disabilities? Which?
__________________________________________________________________________________________
Has the child ever attended any detention centers, alternative schools, and or alternative school settings as a result of

being expelled, dismissed and or suspended from a regular educational setting? If Yes,
Explain.___________________________________________________________________________________

Student Name: _________________________________________________________ Grade_____

Fathers Information:
Fathers Name: ______________________________________________________
Cell Phone:_______________________________ Home E-Mail Address:_______
Employer:__________________________________ Employers Phone #:_______
Work E-Mail Address: ________________________________________________
________ Emergency Contact __________ Allowed to Pick-up Child __________
Mothers Information
Mothers Name: ______________________________________________
Cell Phone:________________________________ Home E-Mail Address:
Employer:___________________________________ Employers Phone #
Work E-Mail Address:_________________________________________________
________ Emergency Contact __________ Allowed to Pick-up Child

Billing Information (Medical Insurance):

Bill to: __________________________________________________________________________________
Billing Address: ___________________________________________________________________________
Street or P.O. Box
City
State
Zip Code
I understand that in the case of injury at school, students will be taken to St. Cloud Hospital for medical
attention.
Parents will be notified immediately.
Insurance Company:__________________________

Policy#__________ Expiration:________________

Policy #: _____________________________________________ Expiration: __________________________

Pick-Up Information: Person (s) Authorized to Pick Up Child from KCS:

Name:
Name:
Name:
Name:

Step-Fathers Information:
Step-Fathers Name:
Cell Phone:
Employer:
Work E-Mail Address:
___________ Emergency Contact ____________ Allowed to Pick-up Child
Step-Mothers Information:
Step-Mothers Name:
Cell Phone:
Employer:

Home E-Mail Address:

Employers Phone #:

Work E-Mail Address:

____________ Emergency Contact ____________ Allowed to Pick-up Child

Academic History:
Was your child in KCS last year? Yes / No Please Circle Your Response
If no, last school attended: ___________________________________________________________________
School Address: ___________________________________________________________________________
Did the child repeat any grades? List Grade: __________ School Phone: ______________________________
How did you hear about KCS? ____________________________________________________________

ST
ATEMENT OF COOPERATION: I certify that the information given is correct and true. In completing this
application for my child it is my desire to have him/her complete the school year. It is also my understanding
that the schools policy is to make no refunds on registration, curriculum, supply, or textbook fees. I understand
the dress and conduct regulations for students of KCS. I will stand behind the school in enforcing these
regulations and will cooperate in seeing that my child abides by these regulations at all times. I understand
that my payments must be made on time, and that records may be withheld if the account is not clear. I pledge
my full cooperation and support to Kingdom Christian School in the education and training of my child.

Parents Signature: ___________________________________________________ Date:_________________

Kingdom Christian School admits students of any race, color and national or ethnic origin.
Please return this form along with applicable fees to the KCS School Office to be eligible for enrollment.