J.E.C.S Registration

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Student Name: *

Nickname *

Please indicate the name your child goes by.

Sex *

Female

Male

Address: *

City: *

State: *

Zip Code: *

Telephone (Home): *

Child's Date of Birth: *

Place of Birth: *

Church Child Attends:

Is Child Baptized:

Yes

Clear selection

Father's Legal Name: *

Relationship: *

Natural

Step-Father

Foster

Telephone (Cell) Father: *

Do You Accept Text Messages: *

Yes

Father's Occupation: *

Father's Work Phone Number: *

Father's Home Phone Number (if different than listed above): *

(If the same, please indicate)

Best Email Address (Father): *

Father's Highest Level of Education: *

High School

Some College

College Degree

U.S. Citizen: *

Yes

Church Affiliation

Marital Status: *

Single

Married to Child's Mother

Married

Divorced

Other

Mother's Legal Name: *

Relationship: *

Natural

Step-Mother

Foster

Telephone (Cell) Mother: *

Do You Accept Text Messages: *

Yes

Mother's Occupation: *

Mother's Work Phone: *

Mother's Home Phone: (If different than listed above) *

(Please indicate if same)

Best Email Address (Mother): *

Mother's Highest Level of Education: *

High School

Some College

College Degree

U.S. Citizen: *

Yes

Mother's Church Affiliation:

Marital Status: *

Single

Married to Child's Father

Married

Divorced

Other

Last School Student Attended: *

Address:

Leave blank if J.E.C.S. last year.

City, State, Zip:

School's Phone Number:

Leave blank if J.E.C.S. last year.

Last Grade Completed by Child: *

Children Within Family: *

Please list children in order of birth including Name, Sex, and Date of Birth (oldest first).

Allergy or Medical Concerns (Please Explain): *

Physician to Call in Emergency: *

Name and Phone Number Please.

Dentist to Call in Emergency: *

Name and Phone Number Please.

#1 Person to Notify in Case of Emergency: *

Please list Name, Relationship, 1st Phone Number and 2nd Phone Number

#2 Person to Notify in Case of Emergency: *

Please list Name, Relationship, 1st Phone Number and 2nd Phone Number

Has student ever been suspended or expelled from any school? *

Yes

If you answered "Yes" to above question, please explain:

Also, please give the contact information of the school involved.

Your child "is" or "is not" covered by health insurance. *

is not

If your child is insured, please indicate the present health insurance company: *

(If not, please indicate by inserting "No" here)

If your child is covered by health insurance, please list policy number here: *

(Please insert "not covered" if not insured)

If your family has a hospital preference, please indicate here: *

Please indicate "any" if you don't have a preference.

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