Ecclesia/Protégé 2018-2019 Application
Email address *
Family Name *
Your answer
Student's first name *
Your answer
Grade in Fall of 2018-2019 *
Your answer
Gender *
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Student email
Your answer
Mother's name (first and last) *
Your answer
Mother's primary phone number *
Your answer
Father's name (first and last)
Your answer
Father's primary phone number
Your answer
Alternate phone number for parents
Your answer
Parents' best contact email address(es) *
Your answer
Emergency Contact (Name, relationship, phone) *
Your answer
Home address (street address, city, zip) *
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Registration status *
Classes (please list all) *
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Are you using charter funds to pay for classes through Protege? If so, please list all. If no, type no *
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I have read an understood the Ecclesia Registration Terms of Agreement *
Required
Signed: *
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A copy of your responses will be emailed to the address you provided.
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