:: Welcome to Midland's Christian Learning Center

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APPLICATION FORM	Please fill out the Student Registration Form and email it to us. Student Registration Card
Student Name:
Student's School Name:
Student's email:
Grade:
Birthday:
Address:
City:
Zip:
Student's Church (if applicable):
Name of Parent/Guardian:
Relationship to student:
Parent Email:
Daytime Phone:
Home Phone:
Health Problems or special needs:
Emergency Contact Information:
Name of person to contact:
Health Problems or special needs:
Relationship to student:
Telephone:
	I, , request that my child be released from during an elective class period to attend a Christian Education class offered by Midlands' Christian Learning Centers. The Christian Learning Centers (CLC) offer classes without regard for race, religion, sex, age, national origin or handicap. By signing below, I understand that CLC has adopted the discipline code of my child's school and that my child may be removed from the CLC program for violations. I give permission for my child to participate in entrance and exit evaluation surveys. I hereby give CLC, their legal representatives and assigns, those acting with permission, or their employee, the right and permission to copyright and/or use, and/or publish, and republish photographic pictures or portraits of my child, including the use of any printed matter in conjunction therewith.