Religious School Registration Form

E3 Preparatory and Leadership Academy Online Registration Form
Student Information
Please note the extensive nature of our form. We ask that you complete all fields so that we are able to meet the needs of your child and family, and in case of emergency we can best care for your child. Thank you so much!

If you need a paper form, please download the Enrollment Packet found on the E3 Preparatory and Leadership Academy website.
Student Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Male or Female?

MaleFemale
Name of School
Grade Level
Parent/Guardian Information
Parent/Guardian 1

First NameLast Name
Home Address 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail 1
Home Phone 1

Area CodePhone Number (xxx-xxxx)
Work Phone 1

Area CodePhone Number (xxx-xxxx)
Cell Phone 1

Area CodePhone Number (xxx-xxxx)
Parent/Guardian 2

First NameLast Name
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail 2
Home Phone 2

Area CodePhone Number (xxx-xxxx)
Work Phone 2

Area CodePhone Number (xxx-xxxx)
Cell Phone 2

Area CodePhone Number (xxx-xxxx)
Child residing with
Emergency Information
Physician's Name
Phone Number

Area CodePhone Number (xxx-xxxx)
Insurance Carrier
Policy #
If Parent or Guardian cannot be contacted:

First NameLast Name
Relationship
Home Phone

Area CodePhone Number (xxx-xxxx)
Cell Phone

Area CodePhone Number (xxx-xxxx)
Work Phone

Area CodePhone Number (xxx-xxxx)
Emergency Medical Treatment
I hereby give my consent to the staff and volunteers of E3 Preparatory and Leadership Academy or person designated as such, to make available to my child/children professional emergency medical care if such care is indicated. I give my permission for my child/children to receive proper medical care by any doctor, nurse, paramedic, or member of a medical staff of a hospital licensed by the State. It is understood that a conscientious effort will be made to notify my spouse/partner or me before such action is taken. It is further understood that every effort will be made to contact my child’s/children's physician prior to any treatment. This is to certify that my child/children is/are in good physical health. He/She/They has/have my permission to participate in all activities that are part of E3 Preparatory and Leadership Academy Programs.

Click here to authorize
Minor Medical Attention/Care
To the best of my knowledge, my child is in good health and able to participate in all E3 PLA activities. I give my permission to E3 PLA to treat minor cuts, scrapes, etc. I release E3 PLA, its employees and representatives from all responsibility for any illness or injury that occurs during E3 PLA activities. I understand that my emergency contact or I will be notified immediately in the event of an emergency.
Click here to authorize
Medical Needs List (In the space provided, for each child please describe and include all medications)
Food Allergies
Insect Bites
Special Diet
Hearing Issues
Learning Issues
ADD/ADHD
Diabetes
Eyesight
Epilepsy
Other
Is there any other information you would like to share with us to help provide your child with the most rewarding educational experience?

All information you share will be kept strictly confidential
Field Trip
I AUTHORIZE my child/children to participate in E3 Preparatory and Leadership Academy field trips and programs. I agree to hold E3 Preparatory and Leadership Academy (including its board, officers, staff and volunteers) harmless from any and all claims that may arise out of his/her/their participation in school trips and programs.
Photograph/Video Release
I grant permission to E3 PLA to use any photographs of my child in future publications and advertising for E3 PLA as well as the E3 PLA website.
Unexcused Absences
I understand that all classes missed must be excused and after missing 3 or more consecutive classes, I will have to pay a re-enrollment fee upon return to class.
Tuition
My Products
prevnext( X )
Registration Fee Per Student$25.00

Quantity

Monthly Installment Fee$ Free

Annual Tuition$ Free

Full Tuition $ Free
ELECTRONIC FUNDS AUTHORIZATION
I authorize E3 Preparatory and Leadership Academy to initiate variable data entries to my account identified below in payment for monthly payments for class tuition. I understand that the Academy will debit my account on the First (1st) of each month or the next business day if that day falls on a Saturday, Sunday, or National holiday. (If the amount changes, I will be notified via email in advance of the withdrawal). I authorize my financial institution (identified below) to debit my account each month on behalf of E3 Preparatory and Leadership Academy. I understand I am in full control of my payment, that I have a right to hold or stop this electronic payment simply by providing the Academy timely written notice. In addition, I will immediately notify the Academy in writing of any changes in the information provided on this authorization form. (MINIMUM of 30 DAYS) I indemnify and hold E3 Preparatory and Leadership Academy, the check processor, and the bank harmless from damage, loss, or claim, resulting from all authorized actions hereunder.

NOTICE: All items returned unpaid are subject to an automatic debit (re-presentment) from my account including a maximum returned check fee as permitted by law.
Select

YesNo
I understand that monthly tuition will not be pro‐rated at any time during the school year; I also understand unpaid tuition can result in accounts being sent to collections agencies for recovery of fees.

I understand that students will not be able to attend classes or participate in activities/events if tuition is not paid by the seventh (3rd) of each month.
Select

YesNo
Please remember that in order for your child to begin class on the first day of school, your E3 Preparatory and Leadership Academy Enrollment forms must be completed in full and the first month of tuition must be paid in advance. Students will not be able to attend classes or participate in events if tuition is not paid by the 3rd of each month.

If you have any questions, please contact the Enrollment Office by emailing: info@e3pla.org.
Once you have completed this form, please click on the submit button below.
Payment Method

I will contact you about using a credit card.I am sending a check or money order.
Should be Empty:

E3 Preparatory and Leadership Academy Online Registration Form

Student Information

Parent/Guardian Information

Emergency Information

Emergency Medical Treatment

Minor Medical Attention/Care

Medical Needs List (In the space provided, for each child please describe and include all medications)

Is there any other information you would like to share with us to help provide your child with the most rewarding educational experience?

Field Trip

Photograph/Video Release

Unexcused Absences

Tuition

Once you have completed this form, please click on the submit button below.