Child's Name *

First/Middle/Last

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father/Guardian Full Name *

First Name

Last Name

Father/Guardian Phone Number *

(###)

###

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Mother/Guardian Full Name

First Name

Last Name

Mother/Guardian Phone Number

(###)

###

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Is your child a Christian? *

Yes

No

If yes, does your child attend church? *

Yes

No

NA

Name *

First Name

Last Name

Phone *

(###)

###

####

Name *

First Name

Last Name

Phone *

(###)

###

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EPEC Tuition *

Tuition for EPEC may be paid in full or divided into 10 equal payments. Tuition for EPEC is due no later than the 10th of each month. Payments received after the 5th will incur a $25 late fee. Students may be asked to leave EPEC if tuition payments are more than 30 days late. I also understand that I am required to give a 30 day written notice if I decide to withdraw my child from EPEC or I will be charged the normal tuition rate.

I agree to pay tuition on time and understand that if I do not, I will incur a $25 fee. I also understand that my child may be asked to leave EPEC if tuition is more than 30 days late. I also agree to give a written 30 day notice if I decide to withdraw my child from EPEC or I will be charged the normal tuition rate.

*

I understand that EPEC Junior Junction is a Christian Educational Center. Students are required to participate in morning prayer, worship, learn Bible stories and verses, follow Christian values/teachings, and talk about theological and spiritual topics.

Name *

First Name

Last Name

Date *

MM

DD

YYYY