Student Enrollment Form ~ 2001/2002

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#666633" TEXT="#080000" bgproperties="fixed" background="087005a2ddvuvs.gif"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Times New Roman" ><B>El Shaddai Ministries of Florida, Inc.</B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="El Shaddai Ministries of Florida, Inc."><U><B>home</B></U></A></div> <bR> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#999966" TEXT="#080000"> <div> <A HREF="id25.htm" TARGET="_top" TITLE="Enrollment Requirements"><U>Enrollment Requirements</U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="Parent/Teacher Responsibility"><U>Parent/Teacher Responsibility</U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="Statement of Faith"><U>Statement of Faith</U></A></div> <div> <A HREF="id41.htm" TARGET="_top" TITLE="Affirmation of Commitment"><U>Affirmation of Commitment</U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Personal or Pastor Reference"><U>Personal or Pastor Reference</U></A></div> <div> <B>Student Enrollment Form ~ 2001/2002</B></div> <div> <A HREF="id31.htm" TARGET="_top" TITLE="Transfer of Records Request"><U>Transfer of Records Request</U></A></div> <div> <A HREF="id33.htm" TARGET="_top" TITLE="Curriculum List"><U>Curriculum List</U></A></div> <div> <A HREF="id32.htm" TARGET="_top" TITLE="Quarterly Reports"><U>Quarterly Reports</U></A></div> <div> <A HREF="id42.htm" TARGET="_top" TITLE="High School Florida Course Codes"><U>High School - Florida Course Codes</U></A></div> <div> <A HREF="id27.htm" TARGET="_top" TITLE="Testing Evaluation Info"><U>Testing & Evaluation Info</U></A></div> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Student Enrollment Form ~ 2001/2002</I></div> <bR> <div> Student Name: _______________________________________      Grade: _______________</div> <bR> <bR> <div> Date: ___________________        DOB: ____________         Age: _______        Sex: _______</div> <bR> <bR> <div> Birth Place:_______________________________      SS#: ___________________________</div> <div> <FONT SIZE="2" COLOR="#000000" FACE="Arial" >                                                                                                         </FONT> (Optional)</div> <bR> <div> Home Phone: _____________________________      Email: __________________________</div> <bR> <bR> <div> Address: ___________________________________________________________________</div> <bR> <bR> <div> Mother's Name: _______________________      Father's Name: ______________________</div> <bR> <bR> <div> Occupation: _________________________       Occupation: _________________________</div> <bR> <bR> <div> Work#:  ______________________________      Work#: ____________________________</div> <bR> <div> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~</div> <div> Do not write below:  For El Shaddai Ministries' administrative use only</div> <bR> <bR> <div> Former School: ________________________________      Withdrawal Date: _______________</div> <bR> <div> <B><U>Checklist for ESM Enrollment</U></B></div> <bR> <div> __ Parent/Teacher Responsibility  __ Student Enrollment Form           __ Birth Certificate</div> <bR> <div> __ Statement of Faith                      __ Transfer of Records Request     __ Immunizations/Waiver</div> <bR> <div> __ Affirmation of Commitment        __ Curriculum/Course List              __ Kindergarten Physical</div> <bR> <div> __ Personal/Pastor Reference       __ Transcripts</div> <bR> <div> <B><U>Attendance/Grades Filed</U></B></div> <bR> <div> 1st Qtr. ____ # Days +  2nd Qtr. ____ # Days + 3rd Qtr. ____ # Days+ 4th Qtr.____ # Days</div> <bR> <div> <B>Total Days of Attendance:  ________</B></div> <bR> <bR> <div> Date Withdrawn from ESM: ______________________        Reason: __________________</div> <bR> <div> Records Forwarded to: __________________________       Date Sent: ________________</div> <div> <I>        </I></div> <div> <I>El Shaddai Academy, 11639 Huggins Street, Leesburg, FL  34788, 352-742-2401</I></div> </td> </tr></table></body>