22-23 Excellence Christian Academy Student Enrollment Form
Fill out the form carefully for each student attending.
Student Name
*
First Name
Middle Name
Last Name
Gender
Male
Female
N/A
Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Student's Age
*
Has your child been suspended or expelled for behavioral reasons?
Previous School Attended and District
Previous School Phone Number
Entering 22-23 Grade Level
*
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Race
American Indian or Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Contact (1)
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
E-mail
*
example@example.com
Work Number
-
Area Code
Phone Number
Place of Employment
Parent Contact (2)
First Name
Middle Name
Last Name
Phone Number
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
E-mail
example@example.com
Work Number
-
Area Code
Phone Number
Place of Employment
Emergency Contacts
The following persons are allowed to pick my child up in my absence.
Emergency Contact (1)
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
E-mail
*
example@example.com
Emergency Contact (2)
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
E-mail
example@example.com
Emergency Contact (3)
First Name
Middle Name
Last Name
Phone Number
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
E-mail
example@example.com
Emergency Contact (4)
First Name
Middle Name
Last Name
Phone Number
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
E-mail
example@example.com
Emergency Contact (5)
First Name
Middle Name
Last Name
Phone Number
-
Area Code
Phone Number
Phone Number
-
Area Code
Phone Number
E-mail
example@example.com
Additional Comments
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Clear Fields
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Medical Information
Does the student pre-existing illness?
*
Yes
No
If YES, what is the condition, please be detailed
What should be done in case of an emergency and which hospital would ?
Is the student on any medications?
*
Yes
No
If YES, please list the medications in detail
List any medication side effects, if applicable
Prescription medicine to be give at school?
*
Yes
No
If Yes, contact the school for additional form to be completed
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Permission to Participate & Handbook Agreement
Please select all that you agree for your student to participate in.
Water Activities
*
Splash Pad/Wading Pool
Swimming Pool (Shallow Only)
Any Water Provided at School
Transportation on ECA Bus
*
Yes
No
Field Trips
*
Yes
No
Technology Use (Internet, Coding, Social Networking under Adult Supervision)
*
Yes
No
In case of emergency, ECA may transport my child to hospital indicated above.
*
Yes
No
I have received a copy of the Excellence Christian Academy rules and policies and understand and agree to comply.
*
Yes
No
Parent/ Guardian Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Student Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
CHILD T-SHIRT SIZE ($10 SPIRIT SHIRT FOR FIELD TRIPS)
2T-4T
5T
YOUTH X-SMALL
YOUTH SMALL
YOUTH MEDIUM
YOUTH LARGE
YOUTH XL
ADULT SMALL
ADULT MEDIUM
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Please insert student photo (headshot in a lit background)
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Please attach student Immunization Records
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If new student, please attach previous report card (if applicable)
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