Eastside Christian School

APPLICATION (click here to print)                                                       Applying for Grade _____

Applicant's name:

____________________________________________________________________________________                            Last                      First                     Middle (required)               Name called          Suffix (Jr., I, II)

Gender:  ___Male  ___Female  Current Grade: _____  Date of Birth:  ___/___/___ 
Age as of September 1, 2013: ____

Home address:  ___________________________________________________________
                          Street                   City                   State            Zip            County
Home phone: ______________

For state reporting purposes, what public school is the applicant eligible to attend: (required)
School Name:  ___________________________      District: (Cobb, Paulding, Marietta): ____________________

Family church affiliation: ________________________________________________________________________

Please list chronologically all other children under the age of 18 living with the family:

Circle all which apply:  The applicant is a sibling of a former student or alumni/child of alumni. 
Year of graduation? ______
Has applicant previously applied or attended ECS?  ____ Yes ____No  If yes, what year? _____

IF divorced, who has primary custody? _______________________
A copy of custody papers must be remitted at family interview.

Student resides with (Check all): __ Father __ Mother __ Stepfather __ Stepmother __ Guardian __ Grandparents

Check title for salutation:
 __ Mr. and Mrs.     __ Mr.    __ Mrs.    __ Ms.    __ Rev. and Mrs.    __ Other____________

Email addresses are required for parent contact information.  The school, PTF and room moms will contact you through email to communicate grade level and event information, including the weekly newsletter.  If you do not wish to have your email address included in receiving reminders, the weekly newsletter, and notices electronically, circle no here: NO

If applicable, please provide the following information on the parent not living with the child:

Full name: _______________________________   Spouse's name: ______________________________________

Home address:____________________________  City, State, and Zip:  __________________________________

Home phone:  ____________________  Cell Phone:  ___________________  Work Phone:  __________________

Occupation/firm name: ___________________________________________

Please send:  ____ No mailings ____ All Mailing and Email Communication

Has the applicant:

Ever repeated a grade:  ____ Yes  ____ No  If yes, what grade? _________

Reason for repeating ____________________________________________________________________________

Ever been diagnosed with learning, social, physical, or emotional disabilities (gifted education, special
learning programs, speech, ADD or ADHD, or occupational therapy etc.)? (Response will be held confidential among school personnel)
____ Yes  ____ No   If yes, please describe:

Ever been referred for or received professional, educational, psychological, or personal counseling or testing?
____ Yes  ____ No 

If yes, the school must be furnished with a copy of the test results at the time the application is submitted.

Ever attended a school or program, and/or received services designed for students who have academic, behavior, or other specific needs (advanced/gifted education, special learning programs, speech, ADD or ADHD or occupational therapy, etc.)? ____ Yes ___ No  If yes, please describe:______________________________________________

Ever been suspended, expelled, or withdrawn from any school for any reason?  ____ Yes  ____ No

Ever had any conduct or discipline problems?  ____ Yes  ____ No

Ever had any involvement with drugs or alcohol?  ____ Yes  ____ No

Ever been brought before the Juvenile Court or law enforcement agency?  ____ Yes ____ No

If yes, to any of the above, an explanation must be provided on a separate page.

Does you child have any ongoing health problems? ____ Yes  ____ No
If yes, please identify:  _________________________________________________________________________

Does the applicant require any daily medication(s):  ____ Yes  ____ No
Name of medication(s):  ________________________________________________________________________

Identify the academic and/or athletic co-curricular activities in which the applicant has interest in participating: