Cornerstone Admissions Form

Grade Entering:
Student's Name: (Last)
(First)
(Middle Initial)
Street Address:
City:
Zip:
Telephone:
Age:
Birth Date:
Race:
Social Security Number:
Gender (M/F):
Father's Name:
Father's Employer:
Work Number:
Pager/Mobile:
Mother's Name:
Mother's Employer:
Work Number:
Pager/Mobile:
Does the student reside with both parents?		Yes     No
If no, guardian's name:
and guardian's address:
Name and current grade of other children presently enrolled at Cornerstone School:
Last school attended:
Last grade completed:
Is student currently enrolled in Special Ed?		Yes     No
If yes, please explain:
Does student have any identified learning difficulties?		Yes     No
If yes, please explain:
Is student hyperactive?		Yes     No
Does student have an attention problem?		Yes     No
If yes, please explain:
Does student have any physical limitations, specific academic needs or special emotional needs?		Yes     No
If yes, please explain:
Has student been under the care of a professional counselor within the last two (2) years?		Yes     No
Please list any medications student takes on a regular basis and reason for this medication:
Name and address of person responsible for finances:
Do you attend church?		Yes     No
If yes, what church?
Are you a member?		Yes     No