Enrollment
School Year ________/________ Date Enrolled _____________
Grade _________
Child’s Name ___________________________ Birth Date ____________
Address _____________________________________________________________
Email ________________________________________________________________
Father/Guardian’s Name __________________ cell phone ___________
Place of Employment ___________________ work phone ___________
Mother/Guardian’s Name ___________________ cell phone __________
Place of Employment _____________________ work phone ___________
Emergency Contacts: in the event that parents cannot be reached
1. ______________________________________________________________
2.
______________________________________________________________
Name of Authorized persons to pick up your child other than parents
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
4.
________________________________________________________________
Please tell us about your child: special interests, favorite color, favorite
Bible Story, etc.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Child’s Physician__________________________
Phone Number ________________
Medical Release
I give my authorization for my child, __________________________ to receive
medical treatment, should an emergency occur when the parent/guardian cannot be
contacted immediately. I understand that in the case of emergency my child will be
taken to ______________________________________ hospital for treatment.
Parent/Guardian Signature:___________________________________________
Date: ______________________
Allergies that
your child may have:
__________________________________________________________________
__________________________________________________________________
List emergency action that needs to take place in case of allergic reaction:
__________________________________________________________________
__________________________________________________________________
List any physical limitations your child may have & accommodations needed:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________
Parent/Guardian Signature Date