Central Bible Academy Contact Information

Contact information

Child's full name

Name child is usually called

Date of birth

School district

Mother's name

Mother's email

This address will receive a confirmation email

Mother's phone

Mother's address

Mother's employer

Mother's church affiliation

Father's name

Father's email

Father's phone

Father's address

Father's employer

Father's church affiliation

Other child care providers

This section is only required if someone other than the parents are keeping the child in the afternoon.

Name of other child care provider

Relationship

Address

Phone

Emergency Contact (if parents cannot be reached)

Name

Relationship

Address

Phone

Child's doctor

Phone

Are immunizations current?

If possible, send the supply fee with enrollment form. It is refundable until August 1 by notifying the director of withdrawal. Thank you! The supply fee can be paid online at SecureGive (opens in new window).

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Central Bible Academy Contact Information

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