PELLA CHRISTIAN HIGH SCHOOL REGISTRATION FORM
First Contact (where student lives)
2017-2018
(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
1.________________________________________
________ __________
______
______________________
2.________________________________________
________ __________
______
______________________
3.________________________________________
________ __________
______
______________________
(*See codes)
*Race Codes: White = W
Asian or Pacific Islander = A
Black = B
Hispanic = H
American Indian or Alaskan Native= AI or AN
Combination of Two or More Races = C
FINANCIAL
Registration Fee:
Family Service Fee:
Student Dues/Fees:
Music Fee:
Hot Lunch:
Less TRIP Credit:
Less Distance Discount
Less ______________
Late Registration Fee
Total Due:
Total Paid:
Check Number:
$ +________ ($300 per student)
$+
150
$ +_________ ($310 per student)-reference the 2017/18 fees sheet
$ +_________ ($50 per student in band and/or choir)
$ +_________ ($45 for one month)
$ - _________
Bill Tuition To:
$ - _________
Father _____
$ - _________
Mother _____
$ +_________ ($50)
Both _______
$__________
$__________
___________
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 Signature
Date
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 Program this year.