Jackson Park Baptist Church - Academy Registration Form Page

Enrolling Student's Information

First Name

Last Name

Birthdate

Gender

Male

Female

Age as of August 31

Who has legal custody of student?

If "Other", who has legal custody of student?

Parent's are:

Church Home?

Primary Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Secondary Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Primary Parent/Guardian Information

First Name

Last Name

Preferred Phone Number

Secondary Phone Number

Employer

Relationship to Student

Father

Mother

Grandparent

Other

If "Other", Relationship to Student

Secondary Parent/Guardian Information

First Name

Last Name

Preferred Phone Number

Secondary Phone Number

Employer

Relationship to Student

Father

Mother

Grandparent

Other

If "Other" Relationship to Student

You will be redirected to the registration payment page. Your registration is not complete until payment is received. Payment can be made online or cash or check can be brought to the church. Please call the church office to make arrangements to make payments in person (704) 932-5015 X2

*All Registration and Tuition fees are non-refundable, if a space is offered.

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Enrolling Student's Information

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

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