School Registration

Parent/Guardian Information
Last Name*
First Name*
Relationship
example Mother, Father
Primary Phone Number*
Secondary Phone Number
Emergency Contact
Last Name
First Name
Primary Phone Number
Secondary Phone Number
Physician and Medical Information
Last Name
First Name
Primary Phone Number
Secondary Phone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Enrollment History
Previous School 1
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 2
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 3
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Should be Empty: