*AA - Admission Application

Child's Information

Child's Name:

Preferred Name / Nickname:

Date of Birth:

Home Address:

Include City, State & Zip Code.

Enrollment Date:

Withdrawal Date:

_______________________________________________________________

Parent/Guardian Name:

Personal Phone:

Home Address

Include City, State & Zip Code.

Place of Business:

Business Phone:

Work Schedule:

____________________________________________________________

Parent/Guardian Name:

Personal Phone:

Home Address

Include City, State & Zip Code.

Place of Business:

Business Phone:

Work Schedule:

______________________________________________________________

Parent's Marital Status:

Is either parent deceased?

Remarried?

Custody arrangements?

Is anyone restricted from seeing or picking up the child(ren)? If yes, please list and provide a copy of the court order.

File upload

_____________________________________________________________

List individuals to notify, in case of emergency, when the parent or guardian cannot be reached.

#1) Name:

Relationship:

Phone Number:

#2) Name:

Relationship:

Phone Number:

List individuals who have permission to pick up your child(ren):

#1) Name:

Relationship:

Phone Number:

#2) Name:

Relationship:

Phone Number: