Summer Fun Registration - 2008  

Date:            

 Student Name:                                              
                       First                             M.I.          Last                              

 Address:                                                                                                             

 Street                                                                 City                           State             Zip

Home Phone:    Cell:           

                                                              

Father                                                    Mother

Student’s Social Security Number:   Date of Birth:

Father’s Name:     Occupation:                                         

Father’s Social Security Number:_____________________________________________

Business Address:                                                                                                                    

Business Phone:__________________________________________________________

Mother’s Name:                                                           Occupation:                                         

Mother’s Social Security Number:____________________________________________

Business Phone: __________________________________________________________

Business Address:                                                                                                                    

Student lives with:  Both Parents ______Father ______Mother ______Guardian_______       

Names and ages of other children:                                                                                            

Previous programs attended:                                                                                                    

Church you attend:                                                                                                                   

Allergies:                                                                                                                                 

Doctor:                                                             Phone: _______________________

Please see reverse side.

Does the student have a medical condition or a learning disability which would require special care or attention during school hours:     (If yes, please explain the details.)                  

We give permission for our child(ren) to take part in all Summer Fun activities.

We give permission for our child(ren) to be photographed for publication, including the school web-site, on behalf of Community Christian Academy .

Signature of Parent Enrolling Child:___________________________________________