APPLICATION FOR ADMISSION TO MOUNTAIN STATE CHRISTIAN SCHOOL

Applicant Information

Full Name: Date:

Last First M.I.

Address:
Street Address Apartment/Unit #

City County State ZIP Code

Phone: Email

Date Available: Social Security No.: Entering Grade:

Reason you are

applying to MSCS:

Parents Information

Mother’s
Name: Date:
Last First M.I.

Address:
Street Address Apartment/Unit #

City County State ZIP Code

Phone: Email

Occupation: ___________________Work Phone: ____________________ Home Phone _____________________

Father’s
Name: Date:
Last First M.I.

Address:
Street Address Apartment/Unit #

City County State ZIP Code

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Phone: Email

Occupation: _________________Work Phone: _______________________Home Phone______________________

Status: Single Married Widowed Divorced Remarried

Education

Name of Address City, St, Zip Phone Start Date End Date Reason for
School Leaving

Honors/Awards

Honor/Award/Activity Organization Date Primary Contact Name Phone & Email

Accomplishments

Personal References

Name Position/Relationship Known How Long? Mailing Address Phone & Email
Pastor
Recommended:

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 Student Profile
Has the applicant ever been suspended or dismissed from school?
If Yes, please provide a full explanation and attach separately. YES NO

Does the applicant currently take any prescription medication? YES NO

If yes, please specify all medications, doses and the reasons taken:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Does the applicant have any disabilities that would limit involvement in P.E. classes? YES NO
If yes, please provide a full explanation and attach separately.

Does the applicant personally desire to attend MSCS? YES NO

This is required for Grades 7 and up. If no, please provide a full explanation
and attach separately.

Church Profile

Family Church Name: _______________________________________________ Attended Since: _____________

Address: _______________________________________________________ State: _______ Zip:____________

Pastor Home ( ) _______________ Church ( ) ____________________ Cell: ( ) _________________

Website: ___________________________________ Email: ______________________________________________

Waiver and Consent

Mountain State Christian School reserves the right to dismiss any student who does not respect its standards or
cooperate in the educational process. As parents, we concur with the following Statement of Faith and give our
permission for Mountain State Christian School to teach the following fundamental doctrines to our child:

We believe in the reliability and Inspiration of the Bible; the Trinity, the deity of Christ; the value and dignity as
well as the sinfulness of man; the offer of forgiveness for sins and assurance of eternal life as a free gift from God
obtained through faith in Christ; the power of the Holy Spirit to purify the Christian and enable him to live a victorious
holy life; the reality of eternal joy or eternal punishment after death; and the Second Coming of Christ.

In making this application, we understand that:

• The teacher has full discretion in the classroom discipline of our child.
• The administration has full responsibility for placing our child in the proper grade.
• Our cooperation is expected in assisting our child with homework and other school work. In payment of
all charges (tuition, books, fees, etc.), and faithfully praying with and for our child.

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We hereby certify that the information on this Application for Admission is true and correct and authorize MSCS to
verify the information provided by contacting the references and church listed. I authorize the references and church
listed to release information they may have regarding the applicant’s character and disposition. Furthermore, I waive
any rights I may have to confidentiality of this information. If the applicant should become enrolled at MSCS, he/she
agrees to abide by the policies of the Parent-Student Handbook. We have read this waiver and are fully aware of its
contents. We sign this consent freely and under no coercion.

__________________________________________ ________________________________________
Signature of Mother Date Signature of Father Date

__________________________________________ ________________________________________
Signature of Applicant (Grades 7 and up) Signature of Administrator Date

For office use only

Received: _______/_________/________ $50 fee paid _______/______/______ Admitted? Y N