PELLA CHRISTIAN HIGH SCHOOL REGISTRATION FORM 2017-2018

First Contact (where student lives) (Circle relationships below that apply)

______

Last Name First Name -Father/Stepfather First Name -Mother/Stepmother

Street Address ______

City, State, Zip Code ______

E-Mail Address(es)______

Home Phone______

Mother Cell phone ______Mother Work Phone ______

Father Cell phone ______Father Work Phone ______

Father/Stepfather Place of Employment ______

Mother/Stepmother Place of Employment______

School District (where student resides)______

Emergency Contact Name______Phone______

(person to contact if we cannot reach a parent)

Church You Attend/City______Pastor’s Name______

Complete this section only if applicable: Second Contact (circle relationships that apply)

______

Last Name First Name - Father/Stepfather First Name – Mother/Stepmother

Home Phone ______E-mail ______

Father/Stepfather Place of Employment ______

Work phone______Cell Phone ______

Mother/Stepmother Place of Employment ______

Work phone ______Cell Phone ______

Street Address ______City, State, Zip ______

NON-DISCRIMINATION POLICY

Pella Christian High School admits students of any race, color, national and ethnic origin to all of the

rights, privileges, programs, and activities generally accorded all students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions and athletic or other school administered policies.

STUDENT NAME(S) – First & Last Name GRADE BIRTHDATE RACE CELL PH NUMBER

(*See codes)

1.______

2.______

3.______

*Race Codes: White = W Black = B American Indian or Alaskan Native= AI or AN

Asian or Pacific Islander = A Hispanic = H Combination of Two or More Races = C

FINANCIAL

Registration Fee: $ +______($300 per student)

Family Service Fee: $ + 150

Student Dues/Fees: $ +______($310 per student)-reference the 2017/18 fees sheet

Music Fee: $ +______($50 per student in band and/or choir)

Hot Lunch: $ +______($45 for one month)

Less TRIP Credit: $ - ______Bill Tuition To:

Less Distance Discount$ - ______Father _____

Less ______$ - ______Mother _____

Late Registration Fee$ +______($50)Both ______

Total Due: $______

Total Paid: $______

Check Number: ______

ACH Debit Form on file-please deduct registration fee on July 24

Full tuition cost per full time student for the 2017/2018 school year is $6,600.00. The balance due after registration fees are paid is $6,300 payable in 9 monthly payments from September 1, 2017 – May 1, 2018. The tuition amount due may change due to financial assistance.

Statement of Agreement:

Recognizing that registration and tuition cover only a portion of the cost of education, we plan, with God’s

help, to contribute time and additional resources to PCHS during the school year.

I hereby affirm that I have read and agree to the terms stated herein. I understand that my child(ren) will be instructed according to the “Philosophy of PCHS”. I agree to the payment plan indicated above and accept the conditions and requirements of all other official school policies and procedures as stated in the Parent-Student Handbook.

______

Parent SignatureDate

Tylenol, Directory and Photo Release:

The parent’s signature on this application provides consent for:

  1. Permission for the office to dispense Tylenol (generic brand) to your children
  2. For parent/student information to be published in the school directory
  3. For the enrolled child(ren)’s picture to be used in publication, school websites, or news releases generated by Pella Christian High School unless the parent specifically indicates otherwise by marking the box(es) below:

☐ Do not dispense Tylenol to my child(ren)

☐ Do not publish my contact information in the school directory

☐ No photo release

Family Service Program:

Y N I (we) plan to volunteer 8 hours of concessions work to the Family Service Programthis year.