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Providence Christian School Northwest

Student Registration Form

STUDENT INFORMATION 2024-2025
Please note:

This form is only for the new students.

This form is to be filled out after booking a tour. If you have not booked a tour, please do so under the Admissions tab on our website. Thank you.
Child's Name*
C Fname C Mname C Lname
Nickname
Gender*
Age*
Date of Birth*
Date Format: MM slash DD slash YYYY
Which grade are you applying for?*
- Preschool
- Kindergarten
- Grade 1
- Grade 2
- Grade 3
- Grade 4
- Grade 5
- Grade 6
- Grade 7
- Grade 8
- Grade 9
- Grade 10
- Grade 11
- Grade 12
Birth Place*
City State / Province / Region Country
Repeat/Skip a grade?*
- Yes
- No
Repeat/Skip Grade*
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code
Had your family been at PCSNW in the past?*
- Yes
- No
FAMILY INFORMATION
Primary Household: Parent / Guardian #1 Information
Parent/Guardian 1 Name*
P1 Fname P1 Lname
Relationship to Child*
Cell Phone*
Home Phone
Is address different than child's, listed on the form?*
Yes
No
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email Address*
Occupation*
Employer*
Work Phone*
Do you want to add a second parent?*
Yes
No
Primary Household: Parent / Guardian #2 Information
Parent/Guardian 2 Name*
First Last
Relationship to Child*
Cell Phone*
Home Phone
Is address different than child's, listed on the form?*
Yes
No
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email Address*
Occupation*
Employer*
Work Phone*
Is there a second household parent/guardian that we should know about?*
Yes
No
Second Household: Parent / Guardian Information
Second Household: Parent/Guardian Name*
First Last
Relationship to Child*
Cell Phone*
Home Phone
Is address different than child's, listed on the form?*
Yes
No
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email Address*
Occupation*
Employer*
Work Phone*
STUDENT PERSONAL INFORMATION
Schools previously attended: Begin with most recent
School Name Phone Number Grade Year

Click ⊕ sign to add more
How many days was your child absent last year?
Tardy?
Please upload copies of your child's most recent year's report card or formal tests that may have been completed at school or at home if homeschooled. If your child's enrollment application is accepted, we will make a Records request from previous schools - but we would like to see how your child is doing academically and behaviorally prior to accepting enrollment.

Drop files here or
Please state your reason(s) for wanting to have your child attend PCSNW.*
STUDENT HISTORY
Has your child ever been suspended or expelled from school?
Yes
No
Does student have any past, current, or pending discipline action at any previous school?
Yes
No
Does your child have any behavioral problems?
Yes
No
If yes, please provide explanation
Does student have any other issues?
Yes
No
If yes, please provide explanation
Does your child have a diagnosed learning disability?
Yes
No
If yes, please describe the area of disability
Provide copies of latest evaluations and assessments

Drop files here or
Does your child participate in a special education program (IEP, 504, Remediation, etc)?
Yes
No
If yes, please explain, describe the program
Provide copies of latest evaluation.

Drop files here or
Emergency Contacts
EC #1: Name
Relationship to child
Phone Number
EC #2: Name
Relationship to child
Phone Number
The following people have my permission to pick up my child from school:
Name
Relationship to child
Phone Number
Name
Relationship to child
Phone Number
Name
Relationship to child
Phone Number
Primary language spoken at home
Ethnic background:
Asian Or Pacific Islander
Black Or African-American
Hispanic, Chicano, or Latino
American Indian/ Alaskan Eskimo
White/Caucasian
Are there any dietary restrictions for your child?
Yes
No
If yes, please explain
Is there anything else you would like us to know?
Parent/Guardian 1 Signature*
Parent/Guardian 2 Signature
Date*
Date Format: MM slash DD slash YYYY
Date
Date Format: MM slash DD slash YYYY
CAPTCHA
Thank you for taking the time to fill out this application as completely as possible. The information contained in it will be kept confidential. Providence Christian School NW admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities general accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, athletics and other school-administered programs.

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