Ezion Fair Christian Community Academy

Ezion Fair Christian Community Academy
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

Month Day Year
Date
HOME ADDRESS
HOME PHONE
CELL PHONE
PERSONAL E MAIL
example@example.com
CITY, STATE, ZIP
GUARDIAN'S NAME
OCCUPATION
WORK ADDRESS
WORK PHONE
ADDITIONAL GUARDIAN
CELL PHONE
CHILDCARE NEEDS:
PROGRAM TOUR DATE

Month Day Year
Date
TYPE OF CARE NEEDS

FULL-TIME PART-TIME
PARENTS INITIALS
DESIRED DATE OF ENROLLMENT

Month Day Year
Date
EXPECTED TO ENROLL UNTIL
IS YOUR CHILD CURRENTLY IN DAYCARE?

YES NO
SIGNATURE

Clear
DATE

Month Day Year
Date
OFFICIAL USE
REJECTED

ACCEPTED DATE:
DATE

Month Day Year
Date
STARTING DATE

Month Day Year
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: