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C.H.A.N.G.E. Membership Application 2014-2015 School Year

(Information is Strictly Confidential)

Parent(s) Names:_____________________________________ ___________________

 

Address:________________________________________________________________

 

City/State/Zip:___________________________________________________________

 

Home Phone:_______________________Work Phone:_________________________

 

Email Address:__________________________________________________________

 

                   Child(ren)ís Name                                                   Date(s) of Birth

___________________________________            _______________________________

___________________________________            _______________________________

___________________________________            _______________________________

___________________________________            _______________________________

___________________________________            _______________________________

___________________________________            _______________________________

 

1.   Why are you homeschooling? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

2.   What school is your child(ren) leaving? (If applicable).

____________________________________________________________________________________________________________________________________________________________________________________________

 

3.   What schools have your children attended?

____________________________________________________________________________________________________________________________________________________________________________________________

 

4.   Has your child ever been in trouble for one or more of the following reasons: drugs, alcohol, profanity, fighting or other violent behavior, disrespect of authority, carrying weapons or any persistent misbehavior? If so, please explain.

____________________________________________________________________________________________________________________________________________________________________________________________

 

5.   What church do you attend?

______________________________________________________________________________________________

 

6.   What class would you like to teach at this co-op?

______________________________________________________________________________________________

 

7.  Any food/drug allergies or medical conditions?

______________________________________________________________________________________________

 

 

SIGNATURE__________________________________________DATE____________

 
 
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