Student's First Name *

Student's Last Name *

Student's Preferred Name *

Student's Gender *

Student's Birthdate *

Student's Current School *

Student's Current Grade *

2021-22 Grade Level Entering *

Dad's First & Last name *

Mom's First & Last Name *

Home Street Address *

City *

State *

ZIP *

Do both parents live at home? *

Dad's Cell Phone Number *

Mom's Cell Phone Number *

Dad's Email Address *

Mom's Email Address *

Describe the student's study/school area at home. *

Does the student have access to appropriate research materials? *

Does the student have access to a mentoring adult who has completed college/has college credit? *

Student History: please provide a brief evaluation of the student's prior academic background. List any formal diagnosis and/or any academic concerns, mental, behavioral, or social issues that are present in your student (ex.: ADHD, etc.) NOTE: undisclosed academic, social, or behavioral issues may result in dismissal from the program. *

What is your family's church? *

Please provide a brief narrative of the parent's faith journey/testimony. *

Is the student a follower of Jesus Christ? *

Parent Signature: I certify that all the above information is true. I understand that my non-refundable registration fee must accompany this application for it to be processed and my student to be considered for the program. I understand that upon acceptance the financial contract with be remitted to me. *