Child’s Last Name
First Name
Date of Birth
Place of Birth (City & State)
Parent’s Name
Address
City
Zip
First Contact Phone Number
Mother’s Work Phone
Father’s Work Phone
Mobile Phone
E-Mail
If Other, Please Specify Relationship
Address
Guarantor
Mother’s Employer
Father’s Employer
List who else is authorized to pick your child from The Academy – (will have to show their picture ID, so please provide their Driver License number). Include spouse if authorized to pick when the child does not live with both parents.
Name Phone No. & relationship
Name Phone No. & relationship
PLEASE PROVIDE IMMUNIZATION RECORDS. IF THE CHILD IS 4 YEARS OR OLDER WE ALSO REQUIRE HEARING AND
VISION TEST RESULT REPORTS.
School Age Children: My child attends the following school and his/her immunization records are on file at that school and immunizations and TB test are current.
Parent (Guardian):Signature
Date
Driver License No
For office use only:
Class
Start Date
Drop Date
Fee($)
Weekly
Monthly
Comments
Emergency Authorization
Child’s Last Name
First Name
Parents’ Names
Address
Guardians Name (If Different From Parents):
Home Phone Number
Mother’s Work Number
Mobile Phone
Father’s Work Number
Mobile Phone
If a parent (guardian) cannot be reached in case of emergency, the Academy has permission to contact the following persons in the order listed:
Name
Phone
Address
Name
Phone
Address
Emergency contacts must be reliable persons, who could make themselves available immediately and who have transportation during your child’s attendance hours. They must be people whom your child knows well, and who can and are ready to pick your child from school and provide care.
Doctor
Phone
Address
Is Your Child Allergic To Any Medication
Pls. Specify
Is Your Child Allergic To Any Other Substance
In case of an emergency, when a parent, guardian, emergency contact, or the above physician cannot be reached, the Academy has my permission to take my child by car, van or ambulance to a hospital. The hospital personnel have my permission to treat the child.
Signature of Parent (or Guardian)
Date
Submit my information
