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FREDERICK DOUGLASS CHRISTIAN SCHOOL

700 Central Avenue ▪ Chester, PA 19013 ▪ 610-499-9030

APPLICATION FOR ENROLLMENT

Information provided in this application, interview and entrance exam is private and will be used only to determine eligibility for FDCS. However, completion of this application does not guarantee acceptance. Incomplete applications will not be considered. Please answer all of the questions completely or mark “N/A” and submit the following items along with this form. 1) Registration fee $100 cash, non-refundable, except ELRC; 2) Child’s birth certificate and SS card; 3) Immunization records and last physical examination;  4) Copy of Insurance Card; 5) Report card and standardized test results, if available; 6) IRS 1040/Official AFDC/Social Security Letter; 7) Expenses: mortgage/lease/rent, utilities (gas & electric, oil, phone, cell, internet, waste removal), food, car note, fuel, auto insurance, medical insurance, daycare/tuition from other schools.

Student's Legal Name

Last

First

Middle

Home Address

Street Address

City

Age

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State

Zip

Grade Entering in the Fall

Mother's Name

Home Phone

Address

Email

Occupation

Employer

Work Phone

Cell Phone

Name Of Church

City

Father's Name

Home Phone

Address

Occupation

Email

Employer

Work Phone

Name Of Church

Cell Phone

City

Who has primary custody of child?

Name

Relationship

Address (If Different From Above)

Street Address

City

State

Zip

Transportation Mode:

(Complete Transportation Enrollment Form)

Signed By:

Printed Name

Thanks for submitting!

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