REGISTRATION FORM for 2010-2011 School Year
DIRECTIONS: (Please read the following before completing the form.)
        1. It is necessary that all information requested on these forms be supplied.  False or
            incomplete information is grounds for immediate dismissal of a student.
        2. Admission to a grade is subject to confirmation by a student’s past school records.
        3. A report card for the end of the previous school year is required for acceptance to E.C.S.
            Entrance exams will be administered during the summer for all new students.
        4. State certification of immunization is required for admission to E.C.S.
        5. I wish to pay my account in the following way:
       __ a.  9 Month Plan;  1st payment due SEPTEMBER 1, 2010
       __ b. 10 Month Plan;  1st payment due AUGUST 1, 2010
       __ c. 12 Month Plan;  1st payment due JUNE 1, 2010

STUDENT INFORMATION:

STUDENT’S NAME ___________________________________________ Male ___Female ___

STUDENT'S SOCIAL SECURITY NUMBER ________________________________________

MAILING ADDRESS ____________________________________________Zip Code________

E-MAIL ADDRESS _____________________________________________________________

PLACE OF BIRTH_______________________________________DATE OF BIRTH _________

TELEPHONE (HOME) ___________________________________  GRADE TO ENTER ______

FAMILY INFORMATION: With whom does the child reside:

FATHER/GUARDIAN                                             MOTHER/GUARDIAN
NAME __________________________________ NAME _______________________________

PLACE OF EMPLOYMENT                                   PLACE OF EMPLOYMENT
_______________________________________   ______________________________________

WORK PHONE _________________________   WORK PHONE ________________________

CELL PHONE ___________________________   CELL PHONE _________________________

Additional individuals permitted to pick up child___________________________________________

_______________________________________________________________________________
 

IF THIS IS YOUR FIRST YEAR AT ESCAMBIA CHRISTIAN SCHOOL,
HOW DID YOU BECOME ACQUAINTED WITH E.C.S.?

     Billboard _________      Bell South Pages _________      Gulf Coast Parent _________

     Friend _____________________________      Other ____________________________
                                (Name)                                                               (Name)
Church preference ______________________________________________________________

Attend where __________________________________________________________________

Minister’s Name ________________________________________________________________

EDUCATION INFORMATION:

Last School Attended ____________________________________________________________

Years Attended ____ Reason for transferring _________________________________________

School Mailing Address __________________________________________ Zip Code _______

Has Child ever repeated a grade? _________  If so, which one? __________________________
(Admission to a grade is subject to confirmation by records.)

STUDENT HEALTH INFORMATION:
Student’s health is:     (   ) Excellent          (   ) Good          (   ) Fair          (   ) Poor

If fair or poor, please explain: ______________________________________________________
_____________________________________________________________________________

Allergies (Medication, Food, Other):_________________________________________________

Does student have any disability that would hinder participation in normal school activities?
(   )  Yes    (   )  No   If YES, please explain: __________________________________________

EMERGENCY INFORMATION:
(If parents cannot be contacted, please list the person who should be contacted.)

Name _____________________________________________________Phone: _____________

Relation to Student ______________________________________________________________

Child’s doctor and phone number __________________________________________________

STATEMENT OF COOPERATION:
I have read and do understand the policy statements regarding payment of account, returned checks
and refunds.  I will cooperate with Escambia Christian School as it endeavors to provide a meaningful
educational experience for my child.

FATHER/GUARDIAN SIGNATURE __________________________________ Date _______

MOTHER/GUARDIAN SIGNATURE _________________________________ Date ________

   ESCAMBIA CHRISTIAN SCHOOL
    3311 West Moreno Street
     P. O. Box 17449
    Pensacola, Florida   32522

EXTENDED CARE REGISTRATION

School hours are 8:00 a.m. to 2:30 p.m.  Morning and afternoon extended care is available.
Morning students may be dropped off from 6:30 a.m. to 7:30 a.m.
Afternoon students may by picked up between 2:45 p.m. and 6:00 p.m.

EXTENDED CARE FEES ARE AS FOLLOWS:

		With In-House Scholarship	With In-House Scholarship
Yearly Fees:	One	TwoStudents from	Three or More
	Student	the same family	Students (same family)
Morning Extended Care only	$ 500.00	$ 650.00	$ 750.00
Afternoon Extended Care only	$1,000.00	$1,300.00	$1,500.00
Morning and Afternoon Extended Care	$1,150.00	$1,500.00	$1,700.00

Yearly Extended Care fees may be paid monthly (10 payments, August-May) and are due
in advance on the first day of each month.

Students picked up after 6:00 p.m. will be assessed a fee of $1.00 per minute.

Students dropped off before 6:30 a.m. will be assessed a fee of $1.00 per minute.

Non-extended care students of E.C.S. may be placed in extended care on a drop-in basis for a flat
daily charge of:

	One Student	Two Students
AM Daily Rate	$ 6.00/day	$ 8.00/day
PM Daily Rate	$12.00/day	$15.00/day
AM/PM Daily Rate	$14.00/day	$16.00/day

PLEASE REGISTER _______________________________________ GRADE ______

   _________ Morning extended care only

   _________ Afternoon extended care only

   _________ Morning & Afternoon extended care

   _________ Drop-In extended care
 
 

_________________                                    _____________________________________
   Date Registered                                          Signature of Parent/Guardian
 Back