REGISTRATION FORM for 2013-2014 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, 2013
        __ b. 10 Month Plan;  1st payment due AUGUST 1, 2013
       __ c. 12 Month Plan;  1st payment due JUNE 1, 2013

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 ________
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