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Pacific Christian Academy
Application For Admission
Applicant
FIRST NAME: MIDDLE:
LAST NAME: NAME USED:
DATE OF BIRTH: GENDER:  MALE FEMALE
YEAR DESIRED: GRADE LEVEL:
ADDRESS: CITY:
STATE: ZIP:
PHONE: FAX:

EMAIL:

ARE PARENTS:

 DIVORCED SEPARATED
If so who does child live with:
Parents or Guardian      
Father/GUARDIAN: Living Deceased  
OCCUPATION: EMPLOYER:
BUSINESS PHONE: RELIGIOUS PREFERENCE:
CONGREGATION: MEMBER: YES      NO
H.S. COMPLETED COLLEGE YEARS

HIGHEST DEGREE HELD:
       

mother/GUARDIAN:

 Living Deceased  
OCCUPATION:

EMPLOYER:
BUSINESS PHONE: RELIGIOUS PREFERENCE:
CONGREGATION: MEMBER: YES      NO
H.S. COMPLETED COLLEGE YEARS

HIGHEST DEGREE HELD:
 
Brothers & Sisters
First Name Last Name School Attending Grade Level Applying to PCA
YES   NO
YES   NO
YES   NO
YES   NO
YES   NO
 
Grandparents
NAME ADDRESS
 
Schools Attended  ( list most recent first )
NAME ADDRESS DATES ATTENDED GRADE LEVELS
 
Extra Curricular Activities:
 
Personal References  
  Address phone
Minister:
Physician:
Principal (last school attended):
   
Other Information  
Please list any Physical, Mental or Emotional Condition of which the Administration should be aware.
Please state briefly reasons for changing schools, if you are transferring.
How did you hear about us? 
Other Information / Comments:

Please make sure form is complete prior to submitting or we may
not be able to complete the review of your application.

Pacific Christian Academy P.O. Box 369 Graton, CA 95444-0369 707.823.2880
 admissions@pacificchristianacademy.org
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Copyright (c) 2003-2009 Pacific Christian Academy
Last Revision: 06.07.09