Afternoon Classes

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All the fields with * are mandatory

Student Name*

Birthday (mm/dd/yyyy)*

Gender*

School Attending*

Grade*

Parent 1 / Guardian 1 Name*

Parent 1 Email*

Parent 1 Home Phone / Work Phone / Cell

Parent 2 / Guardian 2 Name

Parent 2 Email

Parent 2 Home Phone / Work Phone / Cell

In case of emergency, if neither parent cannot be reached, call

Emergency Contact Name 1*

Phone Number*

Emergency Contact Name 2

Phone Number

Pick Up & Delivery Authorization (other than the parents)

Name

Phone Number

Medical Information of the Student

Family Dentist Name

Family Dentist Phone Number

Dentist Office Address

Medical Doctor Name

Doctor Phone Number

Doctor Office Address

Date of Last Physical Exam (mm/dd/yyyy)

List known Allergies or Medical problems below. Input 'None' for no known allergies or reactions. Contact our office for additional forms, if your student has any known allergies or reactions

Known Allergies(if any)

Medical Reactions(if any)

Day of the week for van pick up(3 day minimum)*

Anticipated start date (mm/dd/yyyy)

Tell us about your child(interests, academic level, areas of focus, and your expectations)