Child's Information
Child's Name
First Name
Middle Name
Last Name
Gender
Female
Male
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please provide church affiliation, if any:
Not Regularly/Not members of a church
Members/Regular attendees of a local church
2025-2026 Enrollment
Program
2 Year Old (TTh) $130/month
3 Year Old (MWF) $155/month
4 Year Old (M-F) $250/month
Please list any siblings enrolled in the EBC Day School Program.
Name, Program
Parents/Guardian & Emergency Contact Information
Name
First Name
Last Name
Email
example@example.com
Relationship
Mother, Father, etc
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Name
First Name
Last Name
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Same as above
Child's Secondary Residence
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 1
First Name
Last Name
Relationship
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
First Name
Last Name
Relationship
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Physician Information
Physician's Name
Office Name
Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Date of Last Physical
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the child current on all medical care and vaccinations? (Please submit proof of the same.)
Yes
No
Do you want to add something?
Allergies, Special Care
Acknowledgement: By signing below you are agreeing that all of the information provided on this form is true, that you have the legal authority to enroll your child in this program, and that you will be responsible for the financial obligation to the program once your child's enrollment is confirmed.
Signature
$100 Application fee due by April 1, 2025
All payments should be submitted to the EBC Church Office
Continue
Continue
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