FAMILY INFORMATION

Parent Name (required)

Mailing Address (required)

City (required)

State (required)

Zip Code (required)

Country (required)

Shipping Address (required)

City (required)

State (required)

Zip Code (required)

Country (required)

Primary Phone Number:

Secondary Phone Number:

Your Email (required)

Supervisor of Schoolwork (if other than a parent) Name

Supervisor Mailing Address

Supervisor City

Supervisor State

Supervisor Zip Code

Phone:

How did you hear about Midwest Christian Academy?

STUDENT INFORMATION

Student Name (required)

Gender (required)

Birthday:

Does this student have any learning difficulties? If yes, please describe:

Last School Attended: (required)

Last Grade Completed: (required)

Current Grade (required)

School Address

City

State

Zip Code

Phone:

Fax:

Contact Person

We would like to begin school on this date:

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 on July 1. My student will be supervised during study time by a parent or 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:

Parent Name (required)

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.

Payment Options - Please call (309) 663-4477 with credit card information.

Please be sure to submit this form, then call the office to make your payment.