Elementary Student Survey

Student Name*

Grade Applying For*

In order to enroll a student at Central Arkansas Christian Schools, the parent(s) or legal guardian(s) and prospective student are required to complete this form, sign and return to the admissions office. This information will remain confidential.

Please explain any “Yes” answers on the bottom of this page.

1. Has the student ever been suspended or expelled from school or assigned to an alternative learning center or rehabilitation program?*

Yes
No

2. Is the student ineligible to re-enroll in the school from which he/she is transferring?*

Yes
No

3. Has the student ever been tested/diagnosed with any of the following learning differences: ADHD, Characteristics of Dyslexia, Specific Learning Disability, Autism or other type of learning difference?*

Yes
No

Please specify which of the following learning differences your student has been tested/diagnosed for.

ADHD
Characteristics of Dyslexia
Specific Learning Disability
Autism
Other

4. Has the student ever received services under an Individualized Education Plan (IEP) or 504 Plan?*

Yes
No

5. Is the student now, or have he/she ever been in consultation with a counselor, diagnostician or doctor concerning emotional or behavioral issues?*

Yes
No

6. If transferring from a private school, does your student have a past-due balance?*

Yes
No

7. Does your student currently receive therapy services such as Occupational, Speech, etc.?*

Yes
No

Please explain any "Yes" answers here:

Please list student’s club, organization and co-curricular activities.

Please describe the primary reason for wishing to attend Central Arkansas Christian Schools.

I became aware of Central Arkansas Christian Schools through:*

Applicants Must Demonstrate:

· Composite “C” average in academic classes
· Proficiency on nationally-recognized and norm-referenced tests (i.e., near or above 50th percentile)
· Freedom from severe learning/behavioral problems
· Adherence to CAC’s minimum/maximum age requirement
· A strong desire to be a member of a Christian learning community

Christian Community

The main purpose of Central Arkansas Christian Schools is to train young people to lead fully-developed Christian lives. I understand that this application cannot be approved until admission requirements are met. The Admissions Committee will determine final acceptance of all prospective students. If this application is accepted, I agree to abide by and honor the principles and policies of Central Arkansas Christian Schools.

If accepted, we agree to the immediate dismissal of this student from school for any incorrect or omission of information on this form.

Student Name

Date

Parent/Guardian Signature

Date

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