Confidential Enrollment Form

Confidential Enrollment Form
Full Name of Child
First NameMiddle NameLast NameSuffix
Nick Name of Child
Date of Birth
MonthDayYear
Date
Place of Birth
Gender
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Child is Living With
Both ParentsMotherFatherGuardian
Contact Information
Email
example@example.com
Home Phone Number
Please enter a valid phone number.
Parental Information
Name of Father
First NameLast Name
Employment/Work Position
Work Email
example@example.com
Office Phone Number
Please enter a valid phone number.
Address of Father
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Mother
First NameLast Name
Employment/Work Position
Work Email
example@example.com
Office Phone Number
Please enter a valid phone number.
Address of Mother
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Guardian
First NameLast Name
Employment/Work Position
Work Email
example@example.com
Relationship to Child
Office Phone Number
Please enter a valid phone number.

Other Authorized Persons
Name
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Relationship to Child

Authorization

	Yes	No
Is Person authorized to drop child off to School?
Is Person authorized to pick up child from to School?
Is Person authorized to give consent to medical treatment or medications?
Is Person authorized to give consent to allow child to participate in activities (curricular/extracurricular)?

Child's Health Information
Child's Medical Service
Child's Medicare Number (if applicable)
Name of Pediatrician
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Dietary Restrictions
Medical Allergies
Food Allergies

Legal Restrictions
Please upload any parenting plans granted by the court relative to the child
Cancelof
Please provide details about the court order
Should be Empty:

Contact Information