EIE ACADEMY RENEWAL
201
6-17 SCHOOL YEAR

If you currently enrolled with EIE Academy and wish to renew for the 2016-17 school year,
please fill out this form and send with payment to EIE.  

Family Last Name: __________________________________

Father’s First Name: ______________________ Mother’s First Name: ____________________________

Address: ______________________________ City: ____________________ State: _____   ZIP _______

Phone Number: ________________________   E-Mail Address: _________________________________
(Please be sure to include your e-mail address so we can e-mail important notices in a timely manner.)

Please list names of children enrolling for the 2014-15 school year.
 If last name of child is different
please indicate this on name line.

Name: _________________________________________________ DOB: ___________ Grade: _______

Name: _________________________________________________ DOB: ___________ Grade: _______

Name: _________________________________________________ DOB: ___________ Grade: _______

Name: _________________________________________________ DOB: ___________ Grade: _______

Name: _________________________________________________ DOB: ___________ Grade: _______

Name: _________________________________________________ DOB: ___________ Grade: _______

The tuition for the 2014-15 school year will be $335.00.  If you are adding a new student add $20.00 per
student.  All high school students are assessed a $40.00 surcharge as well.  We accept credit cards, checks
and if you pay in the store we accept cash.  After five days from renewal there are no refunds for tuition or
fees.

Credit Card Number: _____________________________________ Expiration Date________ CCV _________
(CCV Code is the three numbers you will find on the back of your credit card following the credit card
number or the four numbers on your American Express Card.)

TOTAL TUITION AND FEES DUE: _________________  AMOUNT PAID:____________ DUE: ___________
(PLEASE USE AND SUBMIT PAYMENT WORKSHEET ON FOLLOWING PAGE)

Payment Work Sheet:

Tuition:  (Tuition is per family)                                                                                                      $350.00

Registration Fee for new students only: (20.00 per student)                                                         ________
(Maximum of $40.00 per family)

High School Sur-Charge ($40.00 per high school student, maximum $80.00 per
family)                                                                                                                                               ________

Finance Fee:  $35.00  (If you make payments)                                                                                               
________

Total Fee’s Due                                                                                                                              ________

Amount Paid                                                                                                                                    ________

Balance Due                                                                                                                                    ________

Mail this enrollment form and course of study to:

EIE Academy
2640-A7 S. Myrtle Ave.
Monrovia, CA 91016
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Office Use Only:
Date Received: ______________ Payment: _________________ Type: ________________
RENEWAL FORM