STUDENT INFORMATION
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Student Name *
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Student's preferred name *
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Date of birth *
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Gender *
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Male
Female
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Grade entering *
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9
10
11
12
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Ethnicity *
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Caucasian
African
American
Hispanic/Latino
Asian
Middle
Eastern
Pacific
Islander
Native
American
Multi-ethnic
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Home Phone *
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Social Security Number
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For security purposes this information should be provided at the family visit.
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Resides at *
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Mailing Address if different
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FAMILY INFORMATION
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Father's Information
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Father's Name *
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Father's Address *
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Email *
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Home Phone *
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Cell Phone
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Work Phone *
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Employer *
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Occupation *
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Other children in Father's household *
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0
1
2
3
4
5+
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Mother's Information
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Mother's Name *
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Mother's Address *
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Email *
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Home Phone *
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Cell Phone
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Work Phone *
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Employer *
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Occupation *
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Other children in Mother's household *
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0
1
2
3
4
5+
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Other Parent/Guardian #1 (step-parents, etc)
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Name
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Relationship
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Resides with student?
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Yes
No
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Employer
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Home Phone
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Cell Phone
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Work Phone
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Email
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Other Parent/Guardian #2 (step-parents, etc)
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Name
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Relationship
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Resides with student?
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Yes
No
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Employer
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Home Phone
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Cell Phone
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Work Phone
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Email
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Other Emergency Contacts
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Emergency Contact #1
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Phone Number
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Emergency Contact #2
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Phone Number
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SCHOOL INFORMATION
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Current/Previous School *
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Dates attended *
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Address *
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Email *
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Principal *
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School Phone *
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CHURCH INFORMATION
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Church Membership *
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We are
members and attend regularly
We are members and do not attend regularly
We
are not members but attend regularly
We are
not members and do not attend
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Church Attended *
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Denomination *
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Address *
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Phone Number
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Email
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Pastor
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Years attended *
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FINANCIAL INFORMATION
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Person(s) responsible for paying tuition *
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We are applying for Tuition Assistance. (A separate application must be completed.) *
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Yes
No
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Upon acceptance of this application, CORLHS will contact you to discuss payment options.
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STATEMENT OF INTENT - PARENTS
I/We, as parents, as parents, desire a quality, Christ-centered, secondary education for our child, and believe Christ Our Rock Lutheran
High School will provide this type of education. We understand that education includes a partnership between the parents
and the school. Therefore, we will actively support the school and our child’s education and will keep open the lines of
communication between school and home. We hereby acknowledge that acceptance and continuation of attendance at
CORLHS is dependent upon both the students and parents living a lifestyle that is in accordance with Biblical values as
taught and promoted by this school.
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Father
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I agree to the above Statement of Intent.
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Date *
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MM
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/
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DD
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/
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YYYY
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Mother *
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I agree to the above Statement of Intent.
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Date *
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MM
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DD
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/
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YYYY
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STATEMENT OF INTENT - STUDENT
I want to attend Christ Our Rock Lutheran High School and will do my best to be an asset to the student body.
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Student *
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I agree
to the above statement.
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Date *
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MM
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/
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DD
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/
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YYYY
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My above signature signifies that I understand that photographs of applicant taken at school or school sponsored activities may be used for publicity of
Christ Our Rock Lutheran High School. According to FERPA (1974), information will not be disclosed to unprivileged individuals or groups and
information will be given to specific individuals only with proper consent.
My above signature signifies that I give permission to include our name, address, and phone number in the CORLHS directory.
My above signature signifies that I give CORLHS permission to obtain the recommendations required as part of the application process.
Christ Our Rock Lutheran High School admits students of any race, color, sex, and national or ethnic origin to all the rights, privileges, programs and
activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, sex, or national or ethnic
origin in the administration of its educational policies, admission policies, financial assistance, and other school administered programs.
My above signature signifies that I agree to pay the $50 fee for this application.
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Image Verification
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