Elementary School Application Form

Child's Name

First NameLast Name

Child's Birth Date:

MonthDayYear

Address:

Street Address

Street Address Line 2

CityState

Zip Code

Child's School Name

School Name

Child's Teacher's Name

PrefixFirst NameLast Name

Child's Grade

Grade

Mother's/Guardian's Name

First NameLast Name

Mother's/Guardian's Cell Phone Number:

Format: (000) 000-0000.

Mother's/Guardian's E-mail

example@example.com

Father's/Guardian's Name

First NameLast Name

Father's/Guardian's Cell Phone Number:

Format: (000) 000-0000.

Father's/Guardian's E-mail

example@example.com

Family's Church

Church

Is a parent in the military?

Military Parent

Are there any security/custody issues with this child?

If you answered "YES" to the question above, please help us to know the security/custody issues for the safety of your child.

Security/Custody Issues

Does the child have any special needs (ADD, Asperger’s, Dyslexia, etc.)

If you answered "YES" to the question above, please list the special needs of the child. (ADD, Asperger’s, Dyslexia, etc.)

Special Needs

Does your child have any allergies? (peanuts, chocolate, etc.)

If you answered "YES" to the question above, please list your child's allergies.

Allergies

Emergency Contact #1

First NameLast Name

Phone Number

Format: (000) 000-0000.

Emergency Contact #2

First NameLast Name

Phone Number

Format: (000) 000-0000.

In addition to those listed above (Guardian, Parents, & Emergency Contacts), please list the individuals who are also allowed to pick up your child from school.

Allowed to pick up child.

Please list any individual who is NOT allowed to pick up your child from school.

NOT Allowed to pick up child.

My child will get home after club by:

Name

First NameLast Name