Enrollment
Information
Antioch
Christian Academy |
| Child’s Name:
_________________________________________ D.O.B. ________________ |
| Nickname: _________________ Home Phone
____________ Cell Phone: _______________ |
| Address:
__________________________________________ Zip Code:
_________________ |
| Mother’s Name: _________________________________
Driver’s License # _____________ |
| Place of Employment:
__________________________________ Work # ________________ |
| Father’s Name: _________________________________
Driver’s License # _____________ |
| Place of Employment:
__________________________________ Work # ________________ |
| Parent’s Marital Status: (please circle) Married
Separated
Divorced Single
Legal Guardian |
|
Persons authorized to take child from facility
in the event the parent(s) cannot be reached: |
___________________________________________________________________________
Name
Phone #
Address |
___________________________________________________________________________
Name
Phone #
Address |
___________________________________________________________________________
Name
Phone #
Address
|
|
In the event of an emergency where the parents
cannot be reached please notify: |
___________________________________________________________________________
Name
Phone #
Address |
___________________________________________________________________________
Name
Phone #
Address |
___________________________________________________________________________
Name
Phone #
Address |
|
Please indicate the days and times your child (ren)
will be attending and meals that will be consumed:
Breakfast _____ Lunch _____
PM Snack _____ |
| Days attending: Monday___ Tuesday___ Wednesday___
Thursday___ Friday___ |
| Times attending: From ______________ to
_____________ each day. |
| Enrollment Date: _________________________
Withdrawal Date: _____________________ |
| Parent Signature:
____________________________________ Date: ___________________ |
|
Consent for Medical Treatment
|
| As the parent or legal guardian of
______________________________________, I hereby authorize Antioch
Christian Academy to call an emergency ambulance in case of an
accident or acute illness and to arrange for necessary medical and
surgical care in case I am not immediately available. The designated
physician, any licensed physician (M.D.) or dentist (D.D.S.) called
by Antioch Christian Academy may treat and do whatever is necessary
for the health and well being of my child. It is understood that a
conscious effort must be made to notify me (parent) before such
action will be taken. I also agree to accept responsibility for the
cost of medical services. |
| Parent Signature:
____________________________________ Date: ___________________ |
| Child's Physician:
_________________________________ Phone # ____________________ |
| Address:
___________________________________________________________________ |
| Child's Dentist:
___________________________________ Phone #____________________ |
| Hospital Preferred:
________________________________ Phone #____________________ |
| Address:
___________________________________________________________________ |
| Insurance Company: ______________________________
Phone #_____________________ |
| |
