Enrollment Application

Parents or Legal Guardians Information:

 

Person 1- Mother or Guardian 1:


First Middle Last
City State Zip

Person 2- Father or Guardian 2:


First Middle Last
City State Zip

 

Student Information

 

City State Zip

 

Student Program

 

 

How did you hear about us?

 

 

Notes

 

 

Emergency Contacts:

 

Name Relationship to child Address Phone

 

Those authorized to pick up child

 

Name Relationship to child Address Phone

 

Out of state contact:

 

Name Relationship to child Address Phone

 

Child's Siblings:

 

 

Allergies and Food Sensitivities

 

 

Annual Health Assessment

 

 

Has the child been diagnosed with any of the following chronic illnesses or medical conditions:

 

 

Has the child been diagnosed with any of the following disabilities:

 

Type your name
Parent/Guardian eSignature
Parent/Guardian eSignature
Parent/Guardian eSignature
Parent/Guardian eSignature
Parent/Guardian eSignature
Student Name
Parents/Guardian Signature