ACADEMY OF EXCELLENCE APPLICATION FOR ENROLLMENT
Student Information
Child's Full Name:
Last Name
First Name
Middle
Nickname
Date of Birth:
Male
Female
Child's Address:
Primary Hours of Care:
From:
To:
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Family Info:
Child Lives With:
Mother's Name:
Father's Name:
Address:
Address:
Home Phone:
Home Phone:
Employer:
Employer:
Work Address:
Work Address:
Work Phone:
Work Phone:
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Medical Info:
I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.
Doctor 1:
Address & Phone #:
Doctor 2:
Address & Phone #:
Dentist:
Address & Phone #:
Hospital Preference:
Please list allergies, special medical or dietary needs, or other areas of concern:
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Contacts:
Child will be released only to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident, or emergency, if for some reason the custodial parent or legal guardian cannot be reached:
Name 1
Address
Work #
Home #
Name 2
Address
Work #
Home #
Name 3
Address
Work #
Home #
Name 4
Address
Work #
Home #
Name 5
Address
Work #
Home #
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Who Has Custody:
Mother
Father
Both
Other
(specify if other)
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Type your full name:
Your Email Address:
(These will serve as your signature)