Name of Student Enrolling *

First Name

Last Name

Student's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Father/Male Guardian's Name *

First Name

Last Name

Phone Number *

(###)

###

####

Father/Male Guardian's Pastor's Name *

First Name

Last Name

Is the Father/Male Guardian a member of this church? *

Yes

No

Mother/Female Guardian's Name *

First Name

Last Name

Phone Number *

(###)

###

####

Mother/Female Guardian's Pastor's Name *

First Name

Last Name

Is the Mother/Female Guardian a member of this church? *

Yes

No

Student Resides With (Check all that apply) *

Father

Mother

Grandparent

Guardian

Step-Parent

Any Other Children Under 18 Years of Age Living in the Home?

Yes

No

Student is changing schools: *

Voluntarily

Involuntarily (Please Explain Below)

Has your child ever repeated a grade? *

Yes (Please Explain Below)

No

Has your child ever been expelled or suspended? *

Yes (Please Explain Below)

No

Has your child ever been tested for a learning difference, or been placed on an Individual Educational Plan (IEP)? *

Yes (Please attach a copy of test results, and/or IEP, and explain below.)

No

We/I understand that in order for this application to be considered 'complete' and accepted into the admissions process the Pastoral Recommendation must be received by our Admissions Office. *

We/I understand.

We/I certify that the information given on this application is factual and true and based on our/my agreement with the mission and academic philosophy of Hillside Christian Academy. *

Information provided is factual and true.

Application Fee Disclosure *

I understand that in order for this application to be processed the enrollment application fee is required to be mailed to Hillside Christian Academy P.O. Box 193 Lost Creek, WV 26385 in the form of a check or arranged drop-off of a cash payment to the school. (Enrollment Fees based on which enrollment window your application is received. See green blocks at the top of the page for additional details.)

I Understand