2011/2012
Enrollment Application



Family Information

* indicates required fields
*Parent's Name
*Mailing Address
*City

*State *ZIP
*Street (for UPS delivery)
*City

*State *ZIP
*Home Phone
Work Phone
*Daytime Phone
Email
*How did you hear about Midwest Christian Academy?

Supervisor of student's schoolwork if other than parent.
Name
Address
City
State / Zip
/
Phone

Student Information
*Student's Name

Male Female
*Birthdate
Does the student have any learning difficulties? If yes, describe

*Last School Attended
*Last Grade Completed
*Current Grade
School Address
City

State ZIP
*Phone
Fax
Contact Person
*We would like to begin school on

*Month *Day *Year

Enrollment Agreement

I am responsible for the payment of all fees for this account. I understand the registration fee is non-refundable and is to be paid each school year beginning July 1st. My student will be supervised during study time by a parent or a responsible adult who will not allow the student to copy answers from the score keys. I agree to follow the procedures taught in the Parent/Supervisor Training Packet. I will keep all tests and test keys in a secure place inaccessible to the student. I will grade the tests and return them promptly at the end of each quarter.
*I agree to these conditions
*Name
*Date

Fees due with Enrollment Application:
$50 Registration Fee and $30 Diagnostic Testing Fee. After completion of Diagnostic Tests, you may pay annually or quarterly. For a complete current price list, see Registration and Fees page.
Two payment options



Please be sure to submit this form after finishing the PayPal transaction.