Please enable JavaScript in your browser to complete this form.Single Line TextName of child: *Enrollment Type: *New StudentReturning StudentDate of Birth *Age by October 31st *Address: *Home Phone Number: *Mother's Name: *Email: *Address: *Phone #1: *Phone #2: *Name & Address of Employer: *Business Telephone: *Father's Name: *Father's Email: *Father's Address: *Phone #1: *Phone #2: *Name & Address of Employer (Father's): *Business Telephone (Father's): *Please identify an authorized person to pick up/or contact in case of emergency if neither parent is available:Name of 1st Authorized Person: *Relationship to Child: *Address: *Phone #1: *Phone #2: *Name of 2nd Authorized Person: *Relationship to Child *Address of 2nd Authorized Person: *Phone #1: *Phone #2: *I give permission for my child to be photographed or videotaped for The Academy of ELCC use: *YesNoI give permission for my child to participate in neighborhood walking trips around The Academy of ELCC, including trips to and from Eternal Life Christian Center Church: *YesNoList allergies your child has: *Medications/Precautions: *Child's Doctor: *Doctor's Phone Number: *Doctor's Address: *RETURNING STUDENTSIf your child has had a physical and/or immunization since last year’s enrollment and you have not submitted a copy, you must do so with this form. Also, make note that the NJ State Health Department requires that children ages 6-59 months must receive an Influenza vaccine between Sept 1-Dec 31 of each year.ACKNOWLEDGEMENTBy signing below, I give permission to The Academy of ELCC to seek medical care for my child as deemed necessary. I also agree to abide by all policies and procedures, submit all forms completed, to make all registration/book fees and tuition payments as scheduled, and understand that non-compliance by me, my representative or my child will result in the immediate dismissal of my son or daughter.Signature: *Your typed name will represent your signature.Date: *Submit Your Application