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

Does student have a secondary address?

Secondary Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Primary Parent/Guardian Information

First Name

Last Name

Preferred Phone Number

Secondary Phone Number

Email

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

Email

Employer

Relationship to Student

Father

Mother

Grandparent

Other

If "Other" Relationship to Student

Enrolling Student's Information

Primary Parent/Guardian Information

Secondary Parent/Guardian Information

About

Service Times

Contact Info

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