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STUDENT ENROLLMENT FORM

Academic School Year

Grade

Last School Attended

Name of School

Address

Telephone

STUDENT INFORMATION

First Name

Middle Name

Last Name

Date of Birth

City of Birth

Gender

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Home Phone Number

Languages Spoken at Home Other Than English

Does your child currently receive any special education services?YesNo

Please provide the most recent IEP (Individualized Education Plan)

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PARENT INFORMATION

Father’s Full Name

Mother’s Full Name

Home Address (If different than students)

Father’s Cell Phone Number

Mother’s Cell Phone Number

Father’s E-Mail Address

Mother’s E-Mail Address

Siblings (Please list all siblings)

Name

Grade

Date of Birth

Name

Grade

Date of Birth

Name

Grade

Date of Birth

Name

Grade

Date of Birth

PARENT OCCUPATION

Father

Mother

Student Living With:FatherMotherStepfatherStepmotherGrand Parents

Are there any court orders in place regarding your child's educational rights?YesNo

Pick-Up:

Please list names of anyone that will be picking up your child on a regular basis

Name

Relationship

Name

Relationship

Name

Relationship

Custody:

If there is a custody arrangement pertaining to your child, please make us aware of anyone that should not be allowed to pick up or acquire information about your child. *Legal documentation is required.

Please explain

Emergency Contacts

Name

Phone Number

Name

Phone Number

Name

Phone Number

Name

Phone Number

Medical Information

DISABILITIES: Please list any physical limitations or disabilities your child may have and what restrictions they may cause.

ALLERGIES: Please list ALL allergies and medications needed. If your child has a severe food allergy please let us know immediately so we may plan snacks accordingly, as well as post signs in the classroom. We will also have to schedule a meeting with the child’s parents/caregiver to discuss emergency procedures before the child is left in our care.

Child's Doctor Information

Doctor Name

Doctor Phone Number

Street Address

City

State/Province

ZIP / Postal Code

Insurance Information

Policyholder

Group/Member #

Please do not fill in this field.