Registration

Student Information

*First Name:
MI:
*Last Name:
Goes By:
Gender:	M F
Birthdate:
Children:	Child of
Date of Application:
Applying for Grade:
Application for School Year:
Address:
Zip Code:
City:
Home Phone:
School District in which you live:
Are you requesting public school transportation?	Yes No

Family Information

Parent/Guardian 1
Title (Mr., Mrs., Etc.)
First Name:
Last Name:
Relation to Student:
Employer:
Occupation:
Work Phone (ext):
Home Phone:
*Email Address:
Fax #:
Cell Phone:

Parent/Guardian 2
Title (Mr., Mrs., Etc.)
First Name:
Last Name:
Relation to Student:
Employer:
Occupation:
Work Phone (ext):
Home Phone:
Email Address:
Fax #:
Cell Phone:

Person(s) responsible for Tuition:
Daytime Contact Number:
Name:
Emergency care person:
Number:
Address:
Child's Physician:
Number:
State any/all medial or physical problems that your student has that the school needs to be aware of:

May child take Tylenol?	Yes No
May child take IBP?	Yes No
Should the child require medication during the day, all prescription medications must be in the orignal prescription container with the dosage listed on the outside. Should the dosage change, the container will need to reflect that as well.

Church Affiliation:

Name of Church you attend:
Pastor's Name:
Please print out the Pastor Reference Form linked below. Give it to your pastor along with a copy of the Doctrinal Statement Agreement Form (at the bottom) and have him fill it out and give it to the school office.
Pastoral Reference Form
Church Phone number:
Denomination:
Are you a member?	Yes No
How often do you attend?
Please give a brief testimony of your salvation experience:

Please list any Extracirricular Activities or community involvment in which your child participates. Include any awards, honors, etc. that he or she has received.

School attended last year:
Grade:
Address:
Phone:

Please read the following two linked documents. Feel free to save or print them out for further reference.
EBCA Doctrinal Statement Agreement Form EBCA Statement of Cooperation Form
*I, my spouse, and my student have read and agreed to the EBCA Doctrinal Statement Agreement Form.
*I and my spouse have read and agreed to the EBCA Statement of Cooperation Form.

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