Ezion Fair Christian Community Academy (Enrollment Application)

Ezion Fair Christian Community Academy

Enrollment Application
1400 B Street * Wilmington, Delaware 19801 * Ph: 302.652.9114 * Fax: 302.652.7071 www.ezionfairacademy.org
(Please print clearly and respond to all fields)
NAME OF CHILD
GENDER
DATE OF BIRTH

MonthDayYear
Date
HOME ADDRESS
HOME PHONE
Format: (000) 000-0000.
CITY STATE ZIP
CELL PHONE
Format: (000) 000-0000.
PERSONAL EMAIL
example@example.com
GUARDIANS NAME
OCCUPATION
WORK ADDRESS
WORK PHONE
Format: (000) 000-0000.
ADDITIONAL GUARDIAN
CELL PHONE
Format: (000) 000-0000.
CHILDCARE NEEDS:
PROGRAM TOUR DATE

MonthDayYear
Date
PARENTS INITIALS
CHILDCARE NEEDS:
IS YOUR CHILD CURRENTLY IN DAYCARE?
DESIRED DATE OF ENROLLMENT

MonthDayYear
Date
EXPECTED TO ENROLL UNTIL
IS YOUR CHILD CURRENTLY IN DAYCARE?
SIGNATURE
DATE

MonthDayYear
Date
OFFICIAL USE
REJECTED
DATE

MonthDayYear
Date
STARTING DATE

MonthDayYear
Date
SPECIAL NOTES:
ADMINISTRATOR
ASSIGNMENT
EFCCA welcomes families without regard to gender, race, religion, national origin, cultural heritage, political beliefs, family lifestyle, marital status, sexual orientation, or disability.
Should be Empty:

Ezion Fair Christian Community Academy