I Can Christian Learning Acadmey

Register for Pre-School, Grade School & Tutoring Services

Please complete the following information in it's entirety. An incomplete application may delay the processing of your request. If you have any questions regarding registration, please contact our office at (770) 627-3424.

Note: Additional information may be requested to complete your application.

Enrollment Information

Enrollment Date		(e.g. mm/dd/yyyy) (required)
Enrollment Type	Pre-School Grade School Tutoring
Subject(s) Enrolling	Reading Writing Mathematics Note: (applicable for tutoring services only)

Student Information

Name	(required)
Date of Birth		(e.g. mm/dd/yyyy) (required)
Gender	Male Female
Name of School	(required)
School Year	(e.g. 2009-2010) (required)
Grade	(required)
Home Address
City
State
Zip

Parental Information

Parent/Guardian		(required)
Parent/Guardian Title		Mother Father Other
		If other, please specify:
Home
Cellular
Work
Emergency Contact		(required)
Relationship		(e.g. mother, father, sister, etc.)
Emergency Contact #		(required)
How did you hear about us?		(e.g. google, yahoo, friend, etc.)

Payment Preference

I would like to:

Mail my payment Pay online