Enrollment

Child's Full Name *

Birthdate *

Age *

Gender *

Male

Female

Prefer not to say

Home Address *

Country *

State *

City *

Zipcode *

Enrollment Type *

School Year *

Grade Entering*

Programs Interested*

Tuition Type*

Scholarship Award ID

Previous School

Last Grade

Full Name*

Email *

Work Phone

Cell Phone*

Occupation

Employer

Approved for Pickup *

Work Address

Full Name*

Email*

Work Phone

Cell Phone*

Occupation

Employer

Approved for Pickup *

Work Address

Full Name 1 *

Relationship *

Address 2*

Cell Phone*

Full Name 2

Relationship 2

Cell Phone 2

Address

Person 1 Name

Relationship

Phone

Person 2 Name

Relationship

Phone

Person 3 Name

Relationship

Phone

What are your child's primary areas of interest? (Select all that apply)*

Arts & Crafts

Music & Dance

Sports & Physical Activity

Science & Technology

Reading & Storytelling

Outdoor Play

NOTICE TO PARENTS
Students with Disabilities
“A parentally placed private school student with a disability does not have an individual right to receive some or all of the special education and related services that the student would receive if enrolled in a public school under the Individuals with Disabilities Education Act.”

Medical Conditions

Food Allergies*

Special Health Conditions or Disabilities. If no conditions, then put none. *

Other Allergies*

Does your child currently receive any of the following additional support services?*

Speech/Language Therapy

Occupational Therapy

Sports & Physical Activity

ESL (English as a Second Language) Support

Behavioral Support Services

Gifted/Advanced Learner Support

None

Physician Name*

Physician Phone*

Physician Address

Previous School Records

Immunization Record

Physical Examination

Birth Certificate

Scholarship Award Letter

I certify that the information submitted is true and accurate to the best of my knowledge. *

I understand medications must be provided by the parent/guardian in original packaging with clear written instructions. *

I understand all required documents must be submitted before my child may begin school. *

I give permission for school staff to contact emergency medical services if my child requires urgent medical attention and I cannot be reached. *

I agree to the Privacy Policy. *

Parent/Guardian Full Name (Electronic Signature)*

Today's Date *

By submitting this form you agree to the terms of the Privacy Policy and confirm that the information provided is accurate.

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