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VICTORY CHRISTIAN SCHOOL Student Application A ministry of Victory Baptist Church (828) 586-2120 FAX (828-631-9659)
Student’s Full Name ______________________________________ Grade Entering ________________ Returning Student/New Student (Circle One) Male/Female (Circle One) Birth Date ______________ Social Security # _________________ Home Phone # ________________ Student’s Mailing Address ___________________________ _________________ ______ __________ Street/Box City State Zip Code Student Insurance Not Needed/Needed (Circle One) (Additional Cost) Your Insurance Company _____________________________ Your Policy # ______________________ School Last Attended, Grade and Address __________________________________________________ ____________________________________________________________________________________ Has student ever been suspended or expelled? ________ If so, give school name and reason _________ ____________________________________________________________________________________ Any juvenile record? ________ If so, please explain. __________________________________________ ____________________________________________________________________________________ Has student ever been involved in sexual molestation? Yes ____ No ____ If “Yes”, please explain on a separate sheet and attach to this application. _______________________________________________ Student resides with: Father Mother Both Other _____________________ Phone ________________ Father’s Name ___________________________ HM Phone ______________________ WK Phone ______________________ Employer ___________________________ Cell Phone ______________________ Mother’s Name ___________________________ HM Phone ______________________ WK Phone ______________________ Employer ___________________________ Cell Phone ______________________ Church family attends __________________________ Do you attend regularly? Yes No Pastor’s name __________________________ Church Phone __________________________ Child’s Physician ______________________________ Phone ________________________________ Child’s Dentist ________________________________ Phone ________________________________ List any physical problems or Allergies ______________________________________________________ ______ I authorize the staff of VCS to administer medications in accordance with the suggested or prescribed dosages, Initials such as acetaminophen (Tylenol) or diphenhydraine (Benadryl). Please list below any adults we may contact in case of emergency, if parents cannot be reached. Name _________________________ Relationship __________ Phone _______________ Name _________________________ Relationship __________ Phone _______________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I certify that the above information is true and accurate. I am in agreement with the corporal punishment policy. I agree to support the administration, faculty, staff and spirit of Victory Christian School.
_____________________________ _____________________________ ___________________ Signature of parent or guardian Signature of parent or guardian Date
New Families Only: Please give name of person who referred you to Victory Christian School. ____________________________
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