2nd - 12th Grade Application Click here for the PreK - 1st Grade Application "*" indicates required fields 12345 Student InformationStudent Name* First Middle Last NicknameTo be used at school by peers & teachers Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Can the phone number listed above receive SMS messages (text)?*YesNoDate of Birth* Month Day Year Male or Female?* Male Female Is your child a U.S. citizen?* Yes No I-95, Passport or Immigration Number* Date of Entry* Month Day Year Current Grade* Applying for Grade* Academic Year* Please list all schools the applicant previously attended starting with the most recent:*Name of SchoolCity/StatePhone NumberGrade(s) Add Remove Family InformationWith whom does the applicant reside?* Are there special child custody provisions?*If yes, please provide documentation. Yes No Child Custody Documentation*Accepted file types: pdf, doc, docx, Max. file size: 300 MB.Father/Male GuardianName* First Last Email* Primary Phone*Secondary PhoneCan the Primary Phone number receive SMS messages (text)?*YesNoHome Address* Street Address City State / Province / Region ZIP / Postal Code Employer* Employer Address* Street Address City State / Province / Region ZIP / Postal Code Church Now Attending* Pastor* Pastor’s Phone*Church Attendance* Regular Sporadic Seldom Marital Status* Spouse Living at Home Separated Divorced Spouse Deceased Mother/Female GuardianName* First Last Email* Primary Phone*Secondary PhoneCan the Primary Phone number listed above receive SMS messages (text)?*YesNoHome Address* Street Address City State / Province / Region ZIP / Postal Code Employer Employer Address Street Address City State / Province / Region ZIP / Postal Code Church Now Attending* Pastor* Pastor’s Phone*Church Attendance* Regular Sporadic Seldom Marital Status* Spouse Living at Home Separated Divorced Spouse Deceased Are there siblings in the home?* Yes No What are their names and ages?* Financial InformationFinancial obligation for tuitions & fees goes to:* Father Only Both Parents Mother Only Are you interested in applying for financial assistance?* Yes No If someone other than the parent/guardian listed above is responsible for the financial obligations while this student is enrolled at Mount Zion, please complete the following information:Name First Last Relationship to Student Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell PhoneEmail Address Education & HistoryHas the applicant ever been involved in a serious infraction of school rules that caused him or her to be suspended, withdrawn, or expelled from the school?* Yes No If yes, list the offense(s), date(s), and consequencesHas the applicant had any history of excessive tardies or absences from school?* Yes No If yes, explain:* Has the applicant ever received public or private services for an identified learning disability?* Yes No If yes, explain:* Are there any medical diagnoses that could impact his or her success in a classroom environment?* Yes No If yes, explain:* Has the applicant ever been arrested?* Yes No If yes, explain:* Does the applicant have any history of health problems (physical or emotional)?* Yes No If yes, explain:* Is the applicant on medication?* Yes No If yes, type(s)* If yes, what is the intended result(s) of the medication(s)?* Does the applicant have any type of learning disability, difficulty or limitations?* Yes No If yes, explain:* Does the applicant have any type of learning modification or individual education plan (IEP) – past or present?* Yes No If yes, explain:* Has any form of academic/executive functioning testing been done for the applicant in past years?* Yes No If yes, what have been the results of the two most recent tests (include actual copies if possible):*Test Results #1Accepted file types: pdf, doc, docx, Max. file size: 300 MB.Test Results #2Accepted file types: pdf, doc, docx, Max. file size: 300 MB.Is the applicant currently involved in any special programs or receiving any special services from your school or from a private source?*If so, please provide documentation of services provided including dates of services rendered, past or present None Occupational Therapy Speech Therapy Reading Recovery Physical Therapy Special Education Gifted Education/Enrichment Other If other, explain:* If so, please provide documentation of testing, which was done to qualify the applicant.Accepted file types: pdf, doc, docx, Max. file size: 300 MB. Parent InformationPlease write a paragraph or two to describe why you would like your son/daughter to attend Mount Zion Christian Schools:*How did you hear about Mount Zion Christian Schools?* Consent* I understand it is my responsibility to ensure that all the appropriate recommendation forms, as listed below, are delivered to the appropriate individuals and that they have been completed and returned to Mount Zion Christian School in a timely manner.Consent* I have completed this student application truthfully, to the best of my knowledge and give permission for Mount Zion Christian Schools’ administration to call past and current teachers, tutors, administrators and/or pastors. I also certify that I have read the enclosed materials along with this application.Father/Guardian Signature Date Month Day Year Mother/Guardian Signature Date Month Day Year Please list to whom you will be sending reference forms (grades 7 – 12 only).Pastor or Youth Leader* First Last Pastor or Youth Leader Phone*Academic Reference (teacher, principal, guidance counselor)* First Last Academic Reference Phone* Δ