Christian Institute of Arts & Sciences 2007 N. 61st Avenue   * Pensacola , FL 32506   *  Fax 850-458-5132  *  Phone 850-457-4058

        CIAS STUDENT ENROLLMENT FORM


Student Information:

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________________________________________________________________________________

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School History:

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? ________________________________________
 

General Information:

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:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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Is the student on any medication?       Yes     No            If so, please specify: _______________________________________________

Medical Information that CIAS should be aware of:

_________________________________________________________________________________________________________

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Social Security card         Yes     No       

Physical Examination       Yes     No     

Immunization Records      Yes     No                

Cumulative Records         Yes     No

Student Photo                  Yes     No