Request Information

Thank you for your interest in our school!

Please fill out the form below and our Admissions Office will contact you and provide the information you desire.

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Parent / Guardian Information
First Parent / Guardian First Name * Middle Name Last Name * Salutation * Email Address * Confirm Email Address * Gender * Work Phone Cell Phone *	Second Parent / Guardian (leave blank if not applicable) First Name * Middle Name Last Name * Salutation * Email Address * Confirm Email Address * Gender * Work Phone Cell Phone *

Home Address
Street Address * City * Country * State * Zip * Home Phone * How Did You Hear About Us? * Details: Why are you interested in Countryside for your child's education? * Do you currently attend church? * Yes No Name of church attending: * How long have you been attending? * How often do you attend? * Weekly Monthly Seldom Pastor's Name: * Church reference name and contact information: * What are your spiritual goals for your child? * How do you anticipate Countryside Christian School will facilitate the achievement of these goals? Do you have other children who are not applying? * Yes No If yes, please list the grades: Infant PK2 PK3 PK4 Kindergarten 1st-3rd 4th-5th 6th-8th 9th-12th Reason(s) they are not applying: Do you or your child have any relatives or acquaintances our school? Yes No Please list their name: Student 1 First Name * Middle Name Last Name * Birthdate * (mm/dd/yyyy) Gender * Grade Level of Interest * School Year * Current School Student lives with: Both Parents Mother Father Other What school does child currently attend? * Reason for transferring: * Please indicate which program your child is applying for: * Has your child attended daycare/preschool before? * Yes No Are you looking for full or part-time care? * Full-time (5 days/week) Part time (5 Half days/week) Part-time (2 or 3 days/week) Is your child potty trained? * Yes No Is your child currently on scholarship? * Yes No Please indicate which scholarship. * Are you interested in or have you applied for a scholarship (Step Up for Students, AAA, etc)? * Yes No Were there any problems with teacher or administration at previous school? * Yes No Please explain: * Please explain any academic or medical problems your student may be experiencing: Does the student presently have a 504 or IEP? * Yes No Has student ever had disciplinary difficulties or been expelled, dismissed, suspended, or refused admission in another school? * Yes No Please explain: * Has your student ever had a referral? * Yes No Please explain: * Has your student ever used any of the following? * Alcohol Tobacco Drugs None Is There Another Student? Yes No Please wait Parent / Guardian Notes