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1200 City Reservoir Road
Yakima, WA 98908
To Re-Enroll Your Child:
This completed form must be turned in by May 15
Your $50.00 registration fee must be turned in by May 15
Other Required Data (*Must be turned in by June 27, 2014)
Student Information
Name Middle Last    
Address City State Zip
Phone Birthdate Age    
Grade Entering            
Does this student have a signigicant helath issue? If yes, what?
Would you be interested in before and/or after school child care for this student? AM   PM        
Family Information            
Father Name          
Address City State Zip
Home Phone       Cell Phone       Work Phone  
Email Occupation 
Mother Name            
Address City State Zip
Home Phone        Cell Phone        Work Phone  
Email Occupation  
Ethnic Information: (To help YACS fill our UCC, NPUC, State and Federal forms, please share the following information.)
The followng ethnicicites are in the student's background:            
Asian   Black   Caucasian   Hispanic   Native American   Other
*Please check all that apply            
Religious Information:            
Church Membership: 35th Avenue SDA   Fairview SDA    Selah SDA    Wapato Spanish    Other 

Other Denomination
  Baptized Student This Year    
This completed form and $50 pre-registration fee, turned in by May 15, is the first step to insure your student a place in the class for the 2014-2015 school year. Your application packet and student handbook will be mailed the week of June 10.
If your student account is current (no past due balance), your pre-registration fee can be charged to your account.
 My account is current.  Please bill me for the $50 pre-registration fee   
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