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.

__________________________________________________________________


__________________________________________________________________


__________________________________________________________________






Medical

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