Enrollment form | The Academy at Ellison Lakes

Student Information
Family Information
Medical Information
Contacts

Student Information

Family Information

Medical Information

Contact Information

Date of Birth *

Gender *

Preferred Date of Enrollment *

First Name *

Middle Name

Last Name *

Child’s Address

Street *

City *

Zip *

Child Lives With *

Mother's Name

Mother's Address

Mother's Home Phone

Employer

Work Address

Father's Name

Father's Address

Father's Home Phone

Employer

Work Address

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 *

Phone *

Address

Doctor-2

Phone

Address

Hospital Preference

Please list allergies, special medical and dietary needs, or other areas of concern

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

Contact-1 First Name *

Contact-1 Last Name *

Address

Work Phone Number

Home Phone Number *

Cell Phone Number

Contact-2 First Name

Contact-2 Last Name

Address

Work Phone Number

Home Phone Number

Cell Phone Number

Contact-3 First Name

Contact-3 Last Name

Address

Work Phone Number

Home Phone Number

Cell Phone Number

Custody

Mother Father Both Other

Custodian Details (If Other is selected above)

Helpful Information About Child

By entering your name below, you verify that you have received the above items and that all information on this enrollment form is complete and accurate

Full Name *

Today's Date *