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) __________________CELL) ____________  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 ________________________

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:

		TwoStudents from	Each Additional
	One Student	the same family	Student
Morning Extended Care only	$ 50.00/month	$ 60.00/month	$10.00/month
Afternoon Extended Care only	$ 80.00/month	$100.00/month	$20.00/month
Morning and Afternoon Extended Care	$ 90.00/month	$110.00/month	$25.00/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.

Monthly extended care fees are payable in advance and are due on the first of each month.

Non-extended care students of E.C.S. may be placed in extended care on a drop-in basis for a flat charge
of $4.00 for the morning session and $8.00 for one (1) student and $10.00 for two (2) students for the afternoon session.

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