Today's Date *

MM

DD

YYYY

Name of Applicant *

First Name

Last Name

Sex *

Female

Male

U.S. Citizen?

Yes

No

Address 1 *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Father Work/Cell *

(###)

###

####

Mother Work/Cell *

(###)

###

####

Name of Guardian *

First Name

Last Name

Address of Last School Attended *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is This Child a Member of a Church? *

Yes

No

Physician Phone *

(###)

###

####

I Understand the Objectives and Regulations of the Berkshire Hills Christian School and Pledge our Full Support: *

Agree