Santa Rosa Christian School
ACADEMIC EXCELLENCE SINCE 1962
SCHOOL YEAR ________________ DATE ENTERED: _____________________
STUDENT INFORMATION (Youngest to Oldest)
Student 1 Last: ________________________________ First: ___________________ MN: _______________________
Goes By: _________________________ Gender: M/F Date of Birth: ________________ Ethnicity: ______________
Grade Entering: _______________ Email: ______________________________
Last School Attended: __________________________________________ City/State: ______________________
Student 2 Last: ________________________________ First: ___________________ MN: _______________________
Goes By: _________________________ Gender: M/F Date of Birth: ________________ Ethnicity: ______________
Grade Entering: _______________ Email: ______________________________
Last School Attended: __________________________________________ City/State: ______________________
Student 3 Last: ________________________________ First: ___________________ MN: _______________________
Goes By: _________________________ Gender: M/F Date of Birth: ________________ Ethnicity: ______________
Grade Entering: _______________ Email: ______________________________
Last School Attended: __________________________________________ City/State: ______________________
*Additional children can be added on the back
PARENT INFORMATION
Marital Status (circle one): Married Separated Divorced Single Widowed
If parents are separated or divorced, with whom does the child live? _________________________________________
*Note: Legal custodial paperwork must be on file in order to prevent non-custodial parent from seeing or picking up. If
legal paperwork has not been provided, the school is not liable.
Parent 1 Last: _______________________________ First: _______________________ MN: _____________________
Relation: _______________________ Address: ___________________________________________________________
City, State, Zip: ________________________________________ Employer:___________________________________
Home/Cell Phone: ______________________________ Work: ________________________
Email: (Required) ____________________________________________________
Parent 2 Last: _______________________________ First: _______________________ MN: _____________________
Relation: _______________________ Address: ___________________________________________________________
City, State, Zip: ________________________________________ Employer: ___________________________________
Home/Cell Phone: _______________________________ Work: ________________________
Email: (Required) _____________________________________________________
Academy & Preschool New Student Registration Form
EMERGENCY CONTACT Please list anyone (other than parent or guardian) authorized to pick up your student(s)
Contact 1: _____________________________________ Relationship: __________________ Phone: _______________
Contact 2: _____________________________________ Relationship: __________________ Phone: _______________
Contact 3: _____________________________________ Relationship: __________________ Phone: _______________
Contact 4: _____________________________________ Relationship: __________________ Phone: _______________
ALLERGIES OR OTHER MEDICAL ISSUES
List physical impairments, serious allergies, or medications taken on a regular basis:
Student 1:__________________________________________________________________________________________
Student 2:__________________________________________________________________________________________
Student 3:__________________________________________________________________________________________
K2-K4: Please check the following option: Half Day Full Day
Do you need extended care? AM Care PM Care Both
Has your child(ren) failed any grade? Yes No
If yes, give child’s name and grade failed: _________________________________________________________
Has your child(ren) ever been suspended or expelled? Yes No
If yes, give child’s name and reason: _____________________________________________________________
Florida Certification of Immunization, State Birth Certificate, and Student Health Exam Form
is required for all students
STATEMENT OF COOPERATION:
I certify that the information given is correct. In making application for my child, it is my desire to have him/her complete
the school year. I also understand that the school’s policy is to make no refunds on registration or supply fees.
Furthermore, I understand the dress code and conduct regulations for students of SRCS. I will stand behind the school in
enforcing the Handbook and Standards of Conduct (6th-12th) and will cooperate in seeing that my child abides by these
regulations at all times. I understand that my payments must be made on time, and that records may be withheld if the
account is not financially clear. I pledge my full cooperation and support to Santa Rosa Christian School in the education
and training of my child.
Parent’s Signature ___________________________________________________ Date: ________________________
Santa Rosa Christian School admits students of any race, color, national, or ethnic origin. SRCS also maintains the right to
set standards of conduct and can refuse admission to anyone who fails to meet entrance requirements or to whom, in the
opinion of the administration, the school cannot minister effectively.
Mission Statement: Santa Rosa Christian School is dedicated to the spiritual, moral, mental, and social development of
youth through Bible based education.
(Typed Name indicates Signature)
STATEMENT OF COOPERATION AND WAIVER OF LIABILITY
I recognize that attendance at Santa Rosa Christian School and Learning Center (referred to from this
point as SRCS) is a privilege and not a right. Parents are expected to cooperate with and support SRCS
and its teachers in the education and discipline of their child(ren) both in the classroom and during other
related school activities. I believe that discipline is necessary for the welfare of each student, as well as
for the entire school. I give permission for my child’s teacher and/or other agent of the school to make
and enforce classroom regulations in a manner consistent with Christian principles. Students shall forfeit
the privilege of attending SRCS if they do not conform to the standards and way of life at SRCS. SRCS
reserves the right to withdraw a student at any time that the student, in the opinion of and at the sole
discretion of the administration of SRCS, does not conform to the spirit of SRCS.
I further understand that SRCS policy prohibits refunds of all upfront school related fees.
In the event that a SRCS approved photographer or videographer takes a picture with my child in it,
either individually or in a group, I give permission for my child’s picture to be used in future brochures,
videotapes, DVDs, or other publications of SRCS or its affiliated ministries.
I further give permission for my child, whose name is set forth below, to take part in all activities,
including without limitation, transportation to and from school, gymnasium recreational activities, bus
trips, sports activities, field trips on the premises of SRCS and school sponsored trips away from the
SRCS campus. I indemnify and save SRCS, its affiliates, employees, and agents harmless from and
against any claims, demands, causes of action, liability, medical payments, costs and attorneys’ fees
resulting from or arising out of the participation by my child in the above-mentioned activities. I
understand that I am personally and fully responsible for any medical expenses or other liabilities over
and above the medical insurance provided by the third party insurance vendor used by SRCS.
I understand that should my marital status change, it is my responsibility to have a corrected Statement
of Cooperation and Waiver of Liability signed, updated, and delivered to SRCS.
This Statement of Cooperation and Waiver of Liability shall remain in effect for as long as my child
listed (or others to be enrolled) attends SRCS, whether it be in the Learning Center, elementary, middle
school, high school, or summer school. Any reference herein to “child” shall include and refer to all of
the children listed, or others to be enrolled in the future.
Children’s Names and Grades: Signature of Legal Parents/Guardian
___________________________________
___________________________________ Mother Date
___________________________________
___________________________________
___________________________________ Father Date
___________________________________
___________________________________
Sole Guardian Date
____________________________________
____________________________________
_____________________________________
(Typed Name indicates Signature)
How did you hear about SRCS?
_______________________________________________________
Student 4 Last: ________________________________ First: ___________________ MN: _______________________
Goes By: _________________________ Gender: M/F Date of Birth: ________________ Ethnicity: ______________
Grade Entering: _______________ Email: ______________________________
Last School Attended: __________________________________________ City/State: ______________________
Student 5 Last: ________________________________ First: ___________________ MN: _______________________
Goes By: _________________________ Gender: M/F Date of Birth: ________________ Ethnicity: ______________
Grade Entering: _______________ Email: ______________________________
Last School Attended: __________________________________________ City/State: ______________________
Student 6 Last: ________________________________ First: ___________________ MN: _______________________
Goes By: _________________________ Gender: M/F Date of Birth: ________________ Ethnicity: ______________
Grade Entering: _______________ Email: ______________________________
Last School Attended: __________________________________________ City/State: ______________________
List physical impairments, serious allergies, or medications taken on a regular basis:
Student 4:__________________________________________________________________________________________
Student 5:__________________________________________________________________________________________
Student 6:__________________________________________________________________________________________
Other Comments or Information: