Christian Institute of Arts & Sciences
6100-H West Fairfield Drive  Pensacola, fl 32506 fax 850-458-5132  *  phone 850-457-4058


REGISTRATION FORM - FAMILY INFORMATION

Father's Name ______________________________________                                                          

Mother's Name ______________________________________
Marital Status  (please circle one)    Single        Married        Widowed    Divorced
Residence Address _____________________________________________                                               

City ____________________  ST ______  Zip _________

Mailing Address ________________________________________________                                              

City ____________________  ST ______  Zip _________
County of residence _______________________________
Home Phone (_______)_________________________    

Work Phone (_______)__________________________ 
Fax Number  (_______)_________________________    

Email address _________________________________
When is the best time to contact you? ______________   AM   PM

Please list all children living at home:
Name __________________________________________

Date of Birth________________Grade_____________
Name __________________________________________

Date of Birth________________Grade_____________
Name __________________________________________

Date of Birth________________Grade_____________
Name __________________________________________

Date of Birth________________Grade_____________
Name __________________________________________

Date of Birth________________Grade_____________
Name __________________________________________

Date of Birth________________Grade_____________

Father's Occupation______________________________________

Place of employment__________________________________
Is Mother working outside the home?       Yes    No        

If yes, how many hours per day?_________________
Place of employment__________________________________

Father's Skills (educational abilities, talents, hobbies, interests)                        ___________________________________________________________                  
Mother's Skills (educational abilities, talents, hobbies, interests) ___________________________________________________________

Are you a Christian family?   Yes    No                                                                                               

Fellowship or church attending_____________________________________
Attend regularly?    Yes    No                                                                                                                         

How long in attendance?_______________________
Is pastor supportive of home education?   Yes    No  

Family Doctor's Name and telephone number _____________________________________________________
Have you taught your children at home before?      Yes    No   
When?____________________________________________________   

Where?_________________________________________   
Child(ren)'s home education will be under the supervision of:  (circle one)
Both parents              Father primarily        Mother primarily        Guardian   
Other (Please specify) _________________________________________

Are any of the students from a previous marriage?    Yes    No
Step Father's Name ____________________________________

Step Mother's Name ____________________________________
Is the other parent or guardian living in Florida?    Yes    No
What are the custodial arrangements? __________________________________________________________
Is the other parent or guardian supportive of the decision to home educate?    Yes     No
If no, please explain__________________________________________

Have you ever been contacted by HRS?      Yes        No         

If yes, please explain: __________________________________________________________

Briefly state your reasons for choosing home education for your child(ren).  List any information that would help us understand your family situation, such as learning difficulties, skipped or repeated grades, special interests, abilities, family situation, or religious reasons.
____________________________________________________________________
____________________________________________________________________

Please list family businesses, hobbies, or other items of interest:
_______________________________________________________________________
________________________________________________________________________

How did you learn about CIAS? ________________________________________________________________________

ENROLLMENT AGREEMENT

We, as parent(s) and teacher(s) of the aforesaid child(ren), understand and agree that Christian Institute of Arts & Sciences shall not be responsible for the education of our children.  We have read the handbook and agree to uphold and abide by the requirements, policies, and procedures of the Christian Institute of Arts & Sciences, namely: either teach 180 days, or complete the curriculum for the grade level listed above; to keep a record showing attendance, subjects taught, and grades earned in each subject; to submit a copy of the record to the school office quarterly (twice a semester).  We also agree to pay a $5 penalty for each quarterly report and/or tuition that we submit late without prior arrangement with the school administration.  We agree to keep in our home a collection consisting of a list of educational materials used, a lesson plan book, and samples of students' work.  We understand that negligence and neglect of these responsibilities may result in dismissal from the Christian Institute of Arts & Sciences without a refund; and that reinstatement is dependent upon the reaffirmation to these standards and a favorable decision by the school administration.

Father's Signature ________________________Date_________________________
Mother's Signature _________________________Date________________________