Date of Last Upload:
Monday, May 9, 2022
Student Enrollment Form
New Student Information
Select the Submit Application tab after you have filled in all information including students, primary and secondary family, and emergency/contacts. Use the tab buttons to select the pages to fill in the information.
*
Required fields are bold.
Student's Information
Primary Family Information
Secondary Family Information
Contact Information
Submit Application
Student 1
*
Last Name
*
First Name
Middle Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Date of Birth (mm/dd/yyyy)
*
Preferred E-Mail
*
Preferred Phone
Church Affiliation
<None>
None
Other
JCBC member
*
1st Choice Class
<None>
Ones T/Th
Young 2s M/W
2s M/W/F
2s T/Th
Young 3s (M/T/Th)
3s (M/T/Th)
3s (M-Th)
Young 4s (M-Th)
Pre-K (M-Th)
Pre-K (M-F)
Young 5s (M-F)
Alumni
Student 2
*
Last Name
*
First Name
Middle Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Date of Birth (mm/dd/yyyy)
*
Preferred E-Mail
*
Preferred Phone
Church Affiliation
<None>
None
Other
JCBC member
*
1st Choice Class
<None>
Ones T/Th
Young 2s M/W
2s M/W/F
2s T/Th
Young 3s (M/T/Th)
3s (M/T/Th)
3s (M-Th)
Young 4s (M-Th)
Pre-K (M-Th)
Pre-K (M-F)
Young 5s (M-F)
Alumni
Student 3
*
Last Name
*
First Name
Middle Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Date of Birth (mm/dd/yyyy)
*
Preferred E-Mail
*
Preferred Phone
Church Affiliation
<None>
None
Other
JCBC member
*
1st Choice Class
<None>
Ones T/Th
Young 2s M/W
2s M/W/F
2s T/Th
Young 3s (M/T/Th)
3s (M/T/Th)
3s (M-Th)
Young 4s (M-Th)
Pre-K (M-Th)
Pre-K (M-F)
Young 5s (M-F)
Alumni
Student 4
*
Last Name
*
First Name
Middle Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Date of Birth (mm/dd/yyyy)
*
Preferred E-Mail
*
Preferred Phone
Church Affiliation
<None>
None
Other
JCBC member
*
1st Choice Class
<None>
Ones T/Th
Young 2s M/W
2s M/W/F
2s T/Th
Young 3s (M/T/Th)
3s (M/T/Th)
3s (M-Th)
Young 4s (M-Th)
Pre-K (M-Th)
Pre-K (M-F)
Young 5s (M-F)
Alumni
Student 5
*
Last Name
*
First Name
Middle Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Date of Birth (mm/dd/yyyy)
*
Preferred E-Mail
*
Preferred Phone
Church Affiliation
<None>
None
Other
JCBC member
*
1st Choice Class
<None>
Ones T/Th
Young 2s M/W
2s M/W/F
2s T/Th
Young 3s (M/T/Th)
3s (M/T/Th)
3s (M-Th)
Young 4s (M-Th)
Pre-K (M-Th)
Pre-K (M-F)
Young 5s (M-F)
Alumni
Primary Family Information
*
Address Line 1
Address Line 2
*
City
*
State
*
ZIP Code
Parent 1 Information
*
Last Name
*
First Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Mobile Phone
*
Home E-Mail
Company Name
Business Phone
Job Title
Business E-Mail
Is Emergency Contact
Is Allowed to Pickup
Parent 2 Information
*
Last Name
*
First Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Mobile Phone
*
Home E-Mail
Company Name
Business Phone
Job Title
Business E-Mail
Is Emergency Contact
Is Allowed to Pickup
Secondary Family Information
*
Address Line 1
Address Line 2
*
City
*
State
*
ZIP Code
Parent 3 Information
*
Last Name
*
First Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Mobile Phone
*
Home E-Mail
Company Name
Business Phone
Job Title
Business E-Mail
Is Emergency Contact
Is Allowed to Pickup
Parent 4 Information
*
Last Name
*
First Name
*
Preferred Name
*
Gender
<None>
Female
Male
*
Mobile Phone
*
Home E-Mail
Company Name
Business Phone
Job Title
Business E-Mail
Is Emergency Contact
Is Allowed to Pickup
Contact Information (Other than parents)
Contact 1
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Mobile Phone
Is Emergency Contact
Is Allowed to Pickup
Contact 2
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Mobile Phone
Is Emergency Contact
Is Allowed to Pickup
Contact 3
*
Last Name
*
First Name
Relation
<None>
Aunt
Friend
Grandparent
Spouse
Brother
Father
Mother
Uncle
Sister
Mobile Phone
Is Emergency Contact
Is Allowed to Pickup
Medical Contacts
*
Physician
*
Physician Phone Number
*
Insurance
*
Policy Number
*
Insurance Phone Number
*
Hospital
List allergies or medical conditions we should be aware of.
Finished
Confirmation E-Mail address:
Please press the save button to submit the new student application.