CIAS STUDENT ENROLLMENT FORM
Student's Full Name
___________________________________________________
Nick Name (if
any)______________________
Sex: Male _________Female _________
Birthdate _____/_____/_____
Social Security #
_______-________-_______
Number of siblings_______________ Birth
Order_________________
Spiritual
Gift___________________________
Special interests or hobbies_______________________________________________
___________________________________________________________________
___________________________________________________________________
Has student always been home schooled? Yes
No
If not, list name of last school attended
_______________________________________
Last Grade completed ________ When? ____________________
School Address _______________________________________________
City _________________ ST
______ Zip __________
Phone (______)____________________ Fax (______)____________________
Contact person
___________________________
What curriculum was used? ____________________________________________
Does student plan to earn High School Diploma from CIAS?
Yes No Maybe
Please list other information regarding the student's past history that may be
of assistance to CIAS:
_________________________________________________________________
_________________________________________________________________
__________________________________________________________________
Is the student on any medication? Yes
No
If so, please specify:
______________________________________________
Medical Information that CIAS should be aware of: ___________________________
_________________________________________________________________