Christian Institute of Arts & Sciences 2007 N. 61st Avenue  * Pensacola, FL 32506  *  Fax 850-458-5132  *  Phone 850-457-4058 2010-2011 Family Information Form

 Father's Name __________________________________     Mother's Name ____________________________________

Marital Status  (please circle one):                  Single                     Married                  Widowed               Divorced

If divorced:

Step-Mother's Name __________________________    Step-Father's Name _______________________ 

Residence Address ______________________________    City __________________  ST ______  Zip _________

Mailing Address    ______________________________  City  __________________  ST ______  Zip _________

County of residence _____________________________

Home Phone (_______)__________________________   Work Phone (_______)___________________________

Fax Number (_______)__________________________    Email address_______________________________

When is the best time to contact you? _______________   AM   PM

Please list all children living at home:

Name __________________________________________ Date of Birth________________Grade_____________

Name __________________________________________ Date of Birth________________Grade_____________

Name __________________________________________ Date of Birth________________Grade_____________

Name __________________________________________ Date of Birth________________Grade_____________

Name __________________________________________ Date of Birth________________Grade_____________

Father's Occupation________________________________       Place of employment___________________________

Is Mother working outside the home?   Yes    No          If yes, how many hours per day?___________________

Place of employment_______________________________

Father's Skills________________________________________________________________________________                                     
(educational abilities, talents, hobbies, interests)

Mother's Skills_______________________________________________________________________________                                         
(educational abilities, talents, hobbies, interests)

Are you a Christian family?   Yes    No        Fellowship or church attending_______________________________

Attend regularly?    Yes    No                     How long in attendance?____________________________________

Is pastor supportive of home education?   Yes    No  

Family Doctor's Name and telephone number _______________________________________________________

Have you taught your children at home before?      Yes    No   

When?____________________________________________________________________________________   
Where?____________________________________________________________________________________

Child(ren)'s home education will be under the supervision of:  (circle one)

Both parents                   Father primarily                         Mother primarily                 Guardian              

Other (Please specify) ________________________________________________________________________

Are any of the students from a previous marriage?    Yes    No

If Yes, complete the following:

Is the other parent or guardian living in Florida ?    Yes    No

What are the custodial arrangements? ____________________________________________________________

Is the other parent or guardian supportive of the decision to home educate?    Yes     No

If No, please explain__________________________________________________________________________

_________________________________________________________________________________________

Have you ever been contacted by HRS?      Yes        No                  

If Yes, please explain_________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Briefly state your reasons for choosing home education for your child(ren).  List any information that would help us
understand your family situation, such as learning difficulties, skipped or repeated grades, special interests, abilities,
family situation, or religious reasons.

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please list family businesses, hobbies, or other items of interest:

__________________________________________________________________________________________

__________________________________________________________________________________________

How did you learn about CIAS? _________________________________________________________________

Form 2.1, 2.2