Student Info

Member's First Name

Member's Last Name

Date of birth

Gender:

Male

Female

Race

Social Security Number

Grade Level

High School Graduation Year

Prior School/Daycare

Family Last Name

Name Student Goes By

Student Lives With

Referred By

Check Options

Add to mailing list

Publish in school directory

Receive text messages

Add to email list

Address Same As Student

Type of Membership Requested

Student Birth Certificate

Parent Photo ID

Student Updated Physical

Student Updated Dental Exam

Student Letter of Recommendation 1- Professional

Student Letter of Recommendation 2 - Family/Friend

Student Letter of Recommendation 3 - Current Member or Formal Principal/Director

Student Medical/Insurance Card

Student Photo

Intake Conference Form

Parent/Guardian

Mother's Full Name

Father's Full Name

Email *

Phone *

Address

Zip code

Student's Medical

Doctor's Name

Doctor's Contact Number

Dentist's Name

Dentist's Contact Number

Does the student have insurance?

Yes

Insurance Name

Release to give medicine

Yes

Medicine Instructions

Allergies

Other medical notes

Does the student have an IEP/401 Plan/ or any other plan?

Yes

Learning Disability

Authorized Pickup Information

Authorized Pickup#1 Full Name

Full Adress

Relationship to student

Mobile

Authorized Pickup#2 Full Name

Full Address

Relationship to student

Mobile

Policy and Waiver

LIABILITY WAVIER

I hereby certify that my child(ren) is/are in good physical condition and do/does not suffer from any disability that prevents or limits his/her participation in all activities conducted by undefined. I acknowledge that undefined will not assume any responsibility or liability for personal injury or damages caused by the injury. In the event undefined is unable to reach a parent, guardian or any emergency contact, I hereby give permission for my child(ren) to be transported to the nearest hospital for treatment in case of an accident or emergency. I hereby further authorize(s) any of the staff or employees to provide for, approve and authorize health care at hospital.

I've read the above and agree

PHOTO RELEASE

I hereby grant and authorize undefined the right to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of my child(ren) to be used in and/or for legally promotional materials and digital communications. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of and will not be returned.

I've read the above and agree

PLEASE SELECT A DAY TO COME IN AND COMPLETE YOUR ENROLLMENT PROCESS

ALL FORMS ARE DUE WITHIN 2 WEEKS OF BEING ACCEPTED FOR MEMBERSHIP. IF YOUR FORMS ARE NOT RECEIVED YOUR MEMBERSHIP ACCEPTANCE WILL BE CANCELED.