M office use only: Date Received: Amount Paid: Check Number: Amount Due by 8/31 office use only: Amount Due for year: M/W/F a m. p m. ~ Or ~ T/Th k 1 2 3 4 5 6 Book Fee: Supply Fee: $30 Monthly Tuition: Due

M
OFFICE USE ONLY:
Date Received: _____________
Amount Paid: ______________
Check Number: ____________
Amount Due by 8/31________

OFFICE USE ONLY:

Amount Due for year: ____________

M/W/F a.m. p.m. ~ OR ~ T/Th
K 1 2 3 4 5 6
Book Fee:_______ Supply Fee: $30
Monthly Tuition: ______________

Due: August - May
ount Moriah Christian School

P.O. Box 903

30 Church St.

Smithfield, Pa 15478

724-569-4890
RE-Student Enrollment Application

STUDENT’S INFORMATION

Student’s Name _______________________________________________ Age ________

Male ______ Female _______ Birth date ________________ Grade Entering _______
Home Address ______________________________________________________________
______________________________________________________________________________
Phone Number_______________________________________________________________
FATHER’S INFORMATION

Name ____________________________________ Occupation _____________________

Address (IF DIFFERENT FROM STUDENTS) -__________________________________

______________________________________________________________________________

Home Phone __________________________ Cell Phone ________________________
E-Mail Address ______________________________________________________________
Employers Name and Address _______________________________________________

______________________________________________________________________________

Work Phone Number ______________________________________________________
MOTHER’S INFORMATION

Name _____________________________________ Occupation ____________________

Address (IF DIFFERENT FROM STUDENT’S)___________________________________

______________________________________________________________________________

Home Phone ________________________ Cell Phone ___________________________
E-mails address______________________________________________________________
Employers Name and Address _______________________________________________
______________________________________________________________________________
Work Phone Number_________________________________________________________
Marital Status: ____ Single ____ Married ____ Divorced ____ Separated
Custody Arrangement: _____ YES _____ NO (If yes a copy must be on file at school)
MEDICAL INFORMATION

Student’s Doctor _________________________________ Phone __________________

Doctor’s Address_____________________________________________________________
Allergies? If so, What?________________________________________________________
Handicaps / Medical Conditions _____________________________________________
In case of illness or emergency, we will attempt to contact you. In the event that we are unable to reach you, please give the names of at least two other people who are authorized to pick your child up from school.

Emergency contacts will be called in the order you list them.

1. Name _______________________________________ Phone _____________________
Relation to child_____________________________________________________________
2. Name ______________________________________ Phone ______________________
Relation to child______________________________________________________________
Are there any restrictions on who may pick your child up? ___ YES ___ NO
If yes, whom:______________________________________________________________
I hereby give my permission for Mount Moriah Christian School to obtain emergency medical treatment as my be required for my child, and I will assume all costs related to such treatment

____________________________________________________ __________________________________

Signature of Parent Date Signed
TRANSPORTATION INFORMATION Grades K – 6 only, NO Preschool Transportation available.
Will your child need bussing services? YES __________ NO _________

OFFICE USE ONLY:
______ Info sent to bus company
______ Info sent to school district

A.M. ________ P.M. _______ Both _______

What school district do you reside in?

Albert Gallatin ___ Laurel Highlands ___ Uniontown ___ SE Green ____ Brownsville ____

Other (Services may not be available) ____________________________________
REGISTRATION FEES All registration fees are non-refundable.
Preschool – $25.00 Kindergarten – Fifth Grade: $50.00

School information

Present School:_____________________________________ Grade:_______________

Address______________________________________________ Phone:______________
Reason for leaving:__________________________________________________________
Acceptance into MMCS is conditional. If for any reason your application is denied we will refund your registration fee.