Application – Southern Academy Christian School

STUDENT REGISTRATION

Application Status

Full Name of Child *

Email Address *

Gender *

Female
Male

Date of Birth *

Address *

Zip *

Phone *

Mother or Guardian *

Home Address *

Employment *

Work Address *

Employment Phone *

Hours *

Father or Guardian *

People Authorized to pick up your child *

EMERGENCY

Emergency Name One *

People to call in case of EMERGENCY (must list two people; do not list parents of the child

Relationship *

Address *

Day Time Phone No *

Cell Phone No *

Emergency Name Two *

Relationship *

Address *

Day Time Phone No *

Cell Phone No *

Child’s Physician *

Phone No *

Emergency Hospital Preference *

Phone No *

Hospital Address *

Dentist *

Registration Paid *

Received Parent Handbook (initial) *

SOUTHERN ACADEMY

Name of child *

Mother or legal Guardian *

Age *

Father or legal Guardian *

Age *

MARITAL STATUS OF PARENTS

Married *

Living Together *

Stepfather *

Separated *

Stepmother *

Divorced *

Remarks *

Custody/Visiting arrangements *

BROTHERS and SISTERS

Name *

Grade in School *

Name *

Date of Birth *

Grade in School *

Name *

Grade in School *

CHILD EXPERIENCES (Applicable to Pre-K through 1st Grade)

Has child had grouup play experience? *

Where? *

Does child have neighborhood playmates? *

When and with whom does child watch television? *

What are your child’s favorite indoor/outdoor activities? *

Does your child have fears that you are aware of? *

HEALTH HISTORY

Child’s Name *

Date *

High fevers *

Does your child have a history of:

Ear infections *

Colds *

Chicken Pox *

Scarlet Fever *

Diabetes *

Mumps *

Measles *

Is your child on any medication on a daily basis? *

If yes, what *

Has your child ever been hospitalized? *

If yes, for what? *

Has your child had any serious accidents? *

Has your child ever been exposed to peanut products? *

List reactions *

Does your child have any allergies? *

Do you know what the allergy is caused by? *

Asthma *

Signs of reaction:

Difficulty Breathing *

Swelling *

Hay Fever *

Hives *

Other *

Has your child ever seen a dentist *

Who? *

Has your child had a vision screening *

Hearing Tested *

Give a statement of your child’s overall *

DEVELOPMENT HISTORY

Speech *

Do you have any concerns about your child’s development?

Fine motor *

Gross Motor *

Behavior *

Social/Emotional *

What is the dominant language at home? *

What method of discipline is used at home *

What is the child’s reaction? *

How would you describe your child’s personality? *

What are your expectations? *

Please explain any special family traditions or celebrations that you would like to share with us *

Please explain any other information that will help us better understand your child *

Newspapers *

I grant permission to Southern Academy for the following pictures to be taken of my child: Please initial if you agree). Your child’s name may or may not appear in the below:

Center Website *

T.V. *

Displays *

Grant Proposals *

Video *

Parent Signature *

Date *

CONSENT AND CONTACT FORM

Name Of Children *

In the event the child named above is injured or ill, I understand that caregiver will attempt to contact me, the other parent (if applicable) or the legal guardian at the telephone number’s provided below:

Parent or legal guardian’s name *

Telephone Numbers *

Parent or legal guardian’s name *

Telephone Numbers *

In the event that I or the other persons listed on the Emergency assigned by me are not available, I give my permission (as parent or legal guardian) to the caregivers to provide first aid the child named above. I also give permission to take the appropriate measure including contacting the

emergency medical services (EMS) to arrange transportation to *

or the nearest emergency medical facility. At no time will the caregiver drive an ill or injured child to an emergency medical facility. *

Parent or legal guardian’s signature *

Date *

IMPORTANT PARENT INFORMATIO If custody is established through Family Court, ALL papers regarding visitation and primary physical custody MUST be on file with before enrollment of your child. Any changes in the original papers submitted, must be updated with the immediately.