Student's Name:______________________________________________   Preferred Name:_________________________

DOB: __________________________________   Age: ______    M/F   SSN#:  ____________________________________

E-mail Address:  _________________________________________________________________________

Allergies/Health Issues:  ________________________________________________________________________________

Primary Family Information - Who does this child live with?  _____________________________________

Address Line 1: ___________________________________________________________________________                             

Address Line 2: ___________________________________________________________________________

                            ______________________________________________________________________________________   

                                                            City                               State                                          Zip Code                         County

Home Phone #1:  ___________________________________  Home Phone #2: ____________________________________

Father's Information

Father's Name:__________________________________________________________  

Cell Phone: _________________________________________    Home E-Mail Address: ____________________________

Employer:__________________________________________     Employer's Phone #: ______________________________

Work E-Mail Address: __________________________________________________

 ___Emergency Contact                           ___Allowed to Pick-up Child

Mother's Information:

Mother's Name: _________________________________________________________

Cell Phone: _________________________________________    Home E-Mail Address: ____________________________

Employer:__________________________________________     Employer's Phone #: ______________________________

Work E-Mail Address: __________________________________________________

 ___Emergency Contact                           ___Allowed to Pick-up Child

Billing Information:

Bill to:_____________________________________________________________________________________________

Billing Address:           _________________________________________________________________________________

                                 Street or P.O.Box                                       City                                       State                                     ZipCode

I understand that in the case of injury at school, students will  be taken to Santa Rosa Medical Center for medical attention. 

Parents will be notified immediately.

Insurance Company: _______________________________________________________ 

*Florida Certification of Immunization, State Birth Certificate, and Student Health Form is required for all students

Pick-Up Information:

Name: _________________________________________________    Phone:  _____________________________________

Name: _________________________________________________    Phone:  _____________________________________

Name: _________________________________________________    Phone:  _____________________________________

Name: _________________________________________________    Phone:  _____________________________________

Step-Father's Information:

Step-Father's Name: __________________________________________________________  

Cell Phone: _________________________________________    Home E-Mail Address: ____________________________

Employer:__________________________________________     Employer's Phone #: ______________________________

Work E-Mail Address: __________________________________________________

 ___Emergency Contact                           ___Allowed to Pick-up Child

Step-Mother's Information:

Step-Mother's Name:  _________________________________________________________

Cell Phone: _________________________________________    Home E-Mail Address: ____________________________

Employer:__________________________________________     Employer's Phone #: ______________________________

Work E-Mail Address: __________________________________________________

 ___Emergency Contact                           ___Allowed to Pick-up Child

Last school attended:  _________________________________________________________________________________

School Address:  _____________________________________________________________________________________

Repeated Grade?  List Grade:  ____________ How did you hear about SRCS?: _______________________________________

STATEMENT OF COOPERATION:   I certify that the information given is correct.  In making application for my child it is my desire to have him/her complete the school year.  It is also my understanding that the school's policy is to make no refunds on registration, supply, or textbook fees.  I understand the dress and conduct regulations for students of SRCS.  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 Santa Rosa Christian School in the education and training of my child.

Parent's Signature: _____________________________________   Date:______________________________

Santa Rosa Christian School admits students of any race, color, and national or ethnic origin