Records Request Form
Please submit records for the following child to Elizabethtown Christian Academy at 1800 West Broad Street, Elizabethtown, NC 28337 or to Mary Alice Dowd at mdowd@etownecem.org
Child's Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Parent Email
example@example.com
Parent Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Current School Name
Current School Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Current School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates of Attendance
-
Month
-
Day
Year
Starting Date
Dates of Attendance
-
Month
-
Day
Year
Ending Date
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: