Please Complete the following Vital Information
Student Last Name / First Name / Middle name / Nick Name / Ethnic Origin (Check One)___Black ___White __Asian ___Hispanic ___Amer. Indian
Mailing Address / City/State, Zip code / Phone Number / Cell Number
*Social Security Number / Birthdate / Is this a Subsidy Registration? ____yes ____no
Are you receiving any in-house scholarships
_____ yes _____no / Entry Grade
Name of Previous School/Daycare Attended / Previous School/Daycare Address / Previous School/Daycare Zipcode
PARENTAL INFORMATION
Mother Last Name / First Name / Business Phone ( ) Cell Phone ( )
Parent/Guardian Mailing Address (if different from above) / City/State/Zipcode / Workplace Address
Father Last Name / First Name / Business Phone ( ) Cell Phone ( )
Parent/Guardian Mailing Address (if different from above) / City/State/Zipcode / Workplace Address
EMERGENCY CONTACT
List two local persons (other than yourself) who are usually available during the school day and who will agree to pick up, transport and care for your child in the case of an emergency. This information must be updated at all times. Should this information provided be changed at any time the school office must be notified.
**Note: We attempt to contact parents first!!
Name / Relationship to Student / Address / Daytime Phone Number
Name / Relationship to Student / Address / Daytime Phone Number
Enter the name of your child’s pediatrician who the school may contact in case of emergency. Please noted that when the Fire Department Medical Unit responds they will contact the nearest emergency room who may in turn contact your child’s pediatrician.
Child’s Pediatrician / Address / Phone Number
Child’s Dentist / Address / Phone Number
We may on occasions identify opportune moments to take photographs or videotapes in and out of the classroom. Please indicate below whether or not you agree to allow your child to appear in such media products.
____Yes, I agree to allow my child to be in photographed or videotaped
____ No, I do not want my child to be photographed or videotaped
I understand that Harold O. Davis Christian School & Development Center offers a full participation program. I agree to make all payments as scheduled.
Name ______Date ______
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IN-HOUSE
SCHOLORSHIP & INCENTIVES
- Parishioner Scholarship - The Parishioner Scholarship is a $50.00 discount off the monthly tuition. This scholarship is for students who are members of the Harold O. Davis Memorial Baptist Church. As members, parents are responsible to be
- participating tithing members at least twice a month. Two delay in payments will result in a review of tithing practice and a loss of scholarship privileges.
- Sibling Scholarship – The Sibling Scholarship is for families of 2 or more children in attendance. All parents of scholarship recipients are responsible make timely payments. Two delays in payment will result in a loss of scholarship privileges. In an effort to be a blessing to parents of multiple children, the sibling scholarship is as follows:
- Two children - $550.00
- Three children - $750.00
- More than three siblings (request within)
3 Referral Incentive – This incentive is a one-time compensation payment of $75.00 which can be applied toward tuition payment or paid outright. This payment is to anyone who refers a student whose enrollment last at least three months (one quarter).
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OUTSIDE FUNDING
4 CCIS Assistance – This assistance is state funding disbursed to eligible recipients. Per CCIS regulation, these funds must be applied to Before & Afterschool Program services.
5 Outside Scholarship Funds – We accept all outside scholarship funds. All scholarship notices must be received and signed off by the Director in order to be applied to student’s tuition.
**In-house scholarships and incentives cannot be combined with other outside Scholarships or CCIS assistance. Registration and Book Fees must be paid in order to receive scholarships.
FOR OFFICIAL USE ONLY
Date Received ______Reg. Fee Pd (Amt)_____(Date)____ Book Fee Pd. (Amt)_____ (Date) ____
Scholar/Incentives: Sibling Discounts______Parishioner Discount______Referral Discouont______