Application For Re-enrollment

Payment of the $50 re-enrollment fee and $150 curriculum fee must be submitted prior to March 1st! A late fee of $50 will be assessed after the March 1st deadline! Application for busing must be submitted to your district prior to April 1st! Please read the Parent Understanding and Commitment Agreement located on the Admissions Page of this web site prior to submiting this application. If you have no input for a required field just type in "N/A".

Application For Re-enrollment
Today's Date
School Year
Grade Entering
Student's Last Name
Student's First Name
Student's Middle Initial
Student's Home Address
Student's Home City
Student's Home State
Student's Home Zip Code
Home Telephone Number
Public School District
Father's Name
Father's Employment
Father's Work Phone Number
Father's Cell Phone Number
Mother's Name
Mother's Employment
Mother's Work Phone Number
Mother's Cell Phone Number
Indicate Any That Apply Father Deceased
Mother Deceased
Parents Separated
Parents Divorced
Not Applicable
Name of Parent or Guardian With Whom the Child Lives
Preferred E-Mail Address
Church Attending
Church Address
Church City
Church State
Church Zip Code
Pastor's Name
Church Phone Number
Is Father a Christian? Yes
No
Is Mother a Christian Yes
No
Has Student Professed Christ? Yes
No
As this Student's Parent or Guardian Do You Agree to the Upper Room Christian School Parent/Guardian Understanding and Commitment Agreement? Yes
No