First Name:_______________Middle Name:_______________Last Name :_______________________

Address:________________________________City:____________________State: IN Zip:_________

Home Phone:___________________________ Grade:______ Birthdate:_______/_______/_______

Social Security Number:______ - ______ - ______(optional) Gender: M F

Student's Cell Phone # _____________________________________ (optional)

U.S. citizen? Yes No If no, what country ________________/U.S. Entry Date ______________

Mother's First Name:______________________Mother's Last Name:__________________________

Mother's Address___________________________________________________________________

City_____________________State__________Zip____________ Home Phone_________________

Mother's Employer:___________________________ Work Phone #___________________________

Mother's Cell Phone #_____________________ Resides with Mother? Y N

Mother's E-mail Address______________________________________________________________

Father's First Name:______________________Father's Last Name:__________________________

Father's Address___________________________________________________________________

City___________________State__________Zip____________Home Phone #__________________

Father's Employer:________________________________ Work Phone #_____________________

Father's Cell Phone #______________________ Resides with Father? Y N

Father's E-mail Address_____________________________________________________________

Emerg. Contact 1(other than parent)______________________________Phone #________________

Contact 1's Relationship to Student_________________________

Emerg. Contact 2(other than parent)______________________________Phone #________________

Contact 2's Relationship to Student_________________________

Former School_______________________ City & State_________________Date Left___________

Phone #________________________ Counselor/Contact__________________________________

Is your student currently suspended/expelled from former school? Yes No

Has student been suspended/expelled from former school in the past year? Yes No

Has your student ever been enrolled in a NACS school before? Yes No

Does your student have an active IEP (special education) or 504 plan? Yes No

Are you applying for free/reduced lunches & textbook assistance? Yes No

FYI - Upon entering school, all students must meet Indiana State law requirements for immunization. Please note that the law provides for exclusion from school for failure to comply with the immunization law, unless a parent provides a written religious or medical objection.

Minimum Dosage is as follows: DIPHTERIA, TETANUS, PERTUSSIS - 4 Doses **3 doses acceptable if the third dose was administered at age 6 or older. ORAL POLIO - 3 Doses MEASLES, MUMPS, RUBELLA - 2 Doses

Effective August/2006 - Hepatitis B series required for grades 9, 10, and 12