STUDENT REGISTRATION APPLICATION FORM

AND PAYMENT AGREEMENT 2009-2010

PLEASE PRINT OR TYPE STUDENT INFORMATION:

Student's Information

Last Name______________________  First Name ______________________ Middle Name___________________

Student Nickname __________Current Age __ Last Grade___ Proposed New Grade ______

Date of Birth Month_________ Day ___________ Year ___________ Gender: Male _______ Female ________

Student Social Security No. ________-_____-__________   

School District in Which Student Resides                                                                                  

Student Place of Birth

City_____________________ State________ Country ___________________

Estimated distance from campus:                      Actual later confirmed mileage from residence:            

Name of Local School District in which student will reside during the 2008-2009 school term:_____________________ 

Current Address of Student. If the Signer/Payer's Address is different from that of the student, kindly complete signer/payee

complete full residence and contact information on the appropriate section of this document.

House or Apt. No.________________________ Street Name___________________

City____________________ State ______  Zip Code__________ County of Residence of Student ___________________  

Home Telephone No.(     )__________________ Fax (      )_________________

Father's Information

Last Name ____________First Name __________________MN __________

Social Security No. ______-_____-_________ Phone # (       )_______________

E-mail Address _________________________

Street Address ________________________________________________________________

City ______________State _____Zip __________County _______________

Work Phone Number (      ) _________________Work Extension ____________

Work Email Address ____________________________

Employed By (Name of Company or Business ___________________________

Position ____________________ Dept. _____________________________

Lives with Child Y___ N ___ United States Citizen: Yes ___ No. ___Other Country? ____________

Mother's Information

Last Name ________________First Name _______________MN   ____________

Social Security No. _____-_____-______ Phone # (      )_________________

E-mail __________Street Address ___________

City ____________________State ______Zip _________ Country____________________

Work Telephone No.(     ) _____________Work Extension ____________

Work E-mail _______________________

Employed By (Name of Company/Business)  ________________________

Position _______________________________ Dept. ___________________

Lives with Child Y___ N ___ United States Citizen: Yes ___No.___Other Country? __________________________

Emergency Contact # 1

Name of Individual to Call in an Emergency ____________________________________________

Phone (      ) _______________ Relationship to Student __________________

Emergency Contact # 2

Name of Individual to Call in an Emergency _____________________________________________

Telephone (      ) ________________ Relationship to Student    ______________

Physician to Call in Emergency

Telephone (     ) ____________________

Faith Elementary and Middle School Student Registration Application

Male Guardian

Last Name __________First Name _______________MN __________________

Social Security No. ______-_____-________ Phone # (       ) ________________

E-mail Address :________________________

Street Address _________________________

City ____________________State  ______ Zip _______ Country____________________

Work Telephone No.(       ) _____________Work Extension ____________

Work E-mail____________________

Employed By (Name of Company/Business)____________________________________________

Position _______________________________ Dept. __________________________________

Lives with Child Y___ N ___ United States Citizen: Yes ___No.___Other Country? ____________

Female Guardian

Last Name ________________First Name _______________MN ____________

Social Security No. ________-_____-__________ Phone # (      )_____________

E-mail ___________________Street Address _____________________________

City ____________________State ______Zip    __Country__________________

Name of School District in which you reside?                                                         

Approximate Distance from school campus?           Exact Corrected Distance Later After Research :                

Work Telephone No.(      ) _____________      Work Extension ____________

Work E-mail Address ___________________________________

Employed By (Name of Company/Business) ____________________________

Position ___________________ Dept. __________________________________

Lives with Child Y__ N __ U. S. Citizen: Yes __ No. __Other Country? ______

Church Affiliation if any                   ____________________________________                                             

Name of Pastor _______________________ (Denomination if Applicable) ______________________________________

Telephone (      ) _______________ Church E-mail __________________

Name of Church________________________________________________

Street Address_______________________________________

City _______________________State______________Zip Code________

Telephone (      )_______________ Church Fax (      )__________________

Name of Church Clerk or Secretary____________________________

Telephone (      )_______________Fax (      ) ____________

Clerk E-Mail ______________________

Name of Last School Attended  _____________

Name of Principal________________________________________________________

Street Address___________________________________________________________

City _______________________State __________Zip Code__________

School Phone (      )_______________School Fax (      )_______________

Name of Former School  District _________________________________

School District Fax (      ) _____________________

Transportation

Student will arrive at school by: Walk ___ Bicycle ___ Family Vehicle ____

Family Contracted Vehicle ____ Public Transport ___ School Vehicle ___

Last Name _______________First Name ____________MN _______________

U. S. Citizen: Yes ___No.___ Phone Number                                                  

E-mail Address __________________

Street Address ____________________________________

City                                  State           Zip Code             Country_____________

Work Telephone No.(      ) _____________Work Extension ____________

Work E-mail______________________________

Employed By (Name of  Company, ________________  Position ___________ Dept. __________________________________

I am requesting and consenting for my child to be placed in the       Grade and Class. My child has these positive attributes which I believe will assist him or her in being a contributing member of his or her in class __________________

___________________________________.  I believe you may appreciate knowing the following information about my child that may assist the school and  teachers in understanding and being effective in working with my child (ren).                                                                             

Responsible Payer (s)

Important Note: I (We) understand and agree that as the signer (s) of this document, I  am or (we are) responsible for the advance, prompt and regular payment of installments for this account. I, or we understand that the cost for tuition which I (we) agree to pay for this student or these students is $3,500.00 per first child for the academic year, $3,150.00 for a second student from the same household, and $2,975.00 for a third student from the same household. My (Our) signature (s) to this document verifies that I (we jointly) accept that a double installment ($700.00) is due the school to secure the student's seat, prior to the seating of the student for the term. I (we jointly) accept that the remaining eight installments (i.e., $350.00 each) will be paid the school on the first business day of each month (Choice A) September 1, 2009 - April 1, 2010, or (Choice B) October 1, 2009 - May 1, 2010.

I (we jointly) accept Choice A or Choice B. I am writing the letter designating my (our) acceptance of Plan of Choice in the blank that follows: Plan _______, I (we jointly) agree to add the $30.00 late payment fee to my (our) scheduled installment monthly whenever my (our) tuition installment is received by the school after the fifth (5th) calendar day of the month it is due. I agree that any/all late payment fees not paid to the school when due will be held as a debit to the end of the school term to be paid by me (us) prior to issuance of final documents for my (our) child (ren).

It is understood that no credit is extended for student lunch. It is also understood and accepted that Child Care Payments will be paid promptly after billing and not later than fifteen calendar days after issuance of the Statement for Payment by the school. It is anticipated and acceptable to me (us) that my (our) child (ren) will be dismissed from school for habitual non-payment or slow and irresponsible payment of my (our) child's (children') tuition account, or dropped from the Child Care Program for failure to pay timely.