Cornerstone Christian Academy
16010 B Annapolis Road * Bowie, MD 20715 * 3012627683
APPLICATION FOR ADMISSION
Grade Applying for
Month/Year
Date of Application
SECTION I – STUDENT INFORMATION
Name
(Last)
(First)
(Middle)
(Nickname)
Date of Birth
/
/
Gender:
Male
Female (Circle One)
month day year
Address
(Street)
(City)
(State)
(Zip)
Home Phone (
)
Last School Attended
(School Address)
Last Grade Completed
Grade Currently Enrolled
Reason for leaving or wanting to leave previous school
SECTION II – PERSONAL INFORMATION
Has your son or daughter repeated a grade? Yes No
(Circle One)
If yes, please list the grades repeated.
Has you son or daughter had any disciplinary difficulty? Yes No
(Circle One)
If yes, please explain
Has your son or daughter ever been suspended or expelled from any school? Yes No (Circle One)
If yes, please explain
Has your child ever been tested for or diagnosed with a learning disability, ADD, ADHD or bipolar
disorder?
Yes
No
(Circle One)
If yes, please explain
Does your child have any physical or medical disability? Yes
No
(Circle One)
If yes, please explain
Are there any other factors in your child’s life that would impact his/her performance or behavior at CCA
that we should know about such as absence of parent(s), serious accidents, illnesses, adoption, etc.?
Yes
No
(Circle One)
If yes, please explain
SECTION III – FAMILY INFORMATION
Father’s Name
Home Address
Employed By
Position
Home Phone
Work
Cell
Education:
High School Graduate?
Yes No
(Circle One)
College Graduate?
Yes No
(Circle One)
Mother’s Name
Home Address
Employed By
Position
Home Phone
Work
Cell
Education:
High School Graduate?
Yes No
(Circle One)
College Graduate?
Yes No
(Circle One)
Marital Status of parents Married
Divorce
Remarried Single
If separated/divorced, explain legal custody and rights to information
(if requested, we will provide both parents with information unless a court order indicates otherwis