Application Form

Child Information
Childs Name
First Middle Last
Sex Of Child
- Boy
- Girl
Date Of Birth
MM slash DD slash YYYY
Place of Birth
State / Province / Region Country
Primary Language Spoken at Home
Contact Information
Phone
Email
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Mothers Name
First Last
Occupation
Phone
Fathers Name
First Last
Occupation
Phone
Names of Other Children in Home
(Not Applicable if you have no other Children in Home)
Name:
Age
Name:
Age
Name:
Age
Please Indicate Which Schools your Child has Attended
Include the Date Attended To and From AGE: ( Pre School )
Name
Age
Grade
Date
Person to Contact in Case of Emergency, if Parents are Unavailable:
Name
First Last
Phone
Relationship To Child
Health Information for Child
Childs Personal Health Number
Family Doctor
Phone
PLEASE LIST AND MEDICAL CONCERNS THE SCHOOL NEEDS TO BE AWARE OF:
IMMUNIZATION RECORD
** Valid Input: Month / Day / Year
DPT / IPV / HIB
2 Months

Month / Day / Year
4 Months

Month / Day / Year
6 Months

Month / Day / Year
MMR ( 12 Months )

Month / Day / Year
DPT / IPV / HIB / MMR ( 18 Months )

Month / Day / Year
School Entry ( 4-6 Years Old )

Month / Day / Year
Consent*
I agree to the Digital Signature Policy.
BY CLICKING I AGREE ,YOU HEREBY CERIFY THAT ALL THE INFORMATION GIVEN REGARDING YOUR CHILDS REGISTRATION IS DEEMED COMPLETE AND CORRECT.
DIGITAL CONSENT
Name
First Last
Date
MM slash DD slash YYYY

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Child Information