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
CITY STATE ZIP
CELL PHONE
PERSONAL EMAIL
example@example.com
GUARDIANS NAME
OCCUPATION
WORK ADDRESS
WORK PHONE
ADDITIONAL GUARDIAN
CELL PHONE
CHILDCARE NEEDS:
PROGRAM TOUR DATE

MonthDayYear
Date
PARENTS INITIALS
CHILDCARE NEEDS:

Full-TimePart-Time
IS YOUR CHILD CURRENTLY IN DAYCARE?

YESNO
DESIRED DATE OF ENROLLMENT

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

Clear
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