Student Enrollment Application Student Enrollment ApplicationStudent's InformationFirst NameLast NameDate of BirthSchool Child Attends (applies to school age students only)Mother's Information (Guardian #1)First NameLast NameDate of BirthAddressAddress Line 1Address Line 2CityStateZip CodeCell Phone NumberEmail AddressEmployerEmployer's AddressWork Phone NumberFather's Information (Guardian #2)First NameLast NameDate of BirthAddressAddress Line 1Address Line 2CityStateZip CodeCell Phone NumberEmail AddressEmployerEmployer's AddressWork Phone NumberEmergency Contact Information (other than Parents/Guardians mentioned above.)First ContactFirst NameLast NameFull AddressHome Phone NumberCell Phone NumberRelationship to studentSecond ContactFirst NameLast NameFull AddressHome Phone NumberCell Phone NumberRelationship to student These emergency contacts listed above will be allowed to pick up your child, and do not need to be listed below in the next section of additional parental authorizations.Additional Parental AuthorizationsNameNameNameNameNameNameRelationship to StudentRelationship to StudentRelationship to StudentRelationship to StudentRelationship to StudentRelationship to StudentCell Phone NumberCell Phone NumberCell Phone NumberCell Phone NumberCell Phone NumberCell Phone Number Kid Academy will only release your child to those listed on this application unless we received WRITTEN authorization from parents IN PERSON. Anyone unfamiliar will be asked to show picture identification. This policy is strictly enforced for the safety of our students.Special information concerning student's growth development and needsIs your child toilet trained? Yes NoIf not, document when applicableAllergic Reactions (must provide detailed doctor's note as stated in our handbook)Private Physician or Medical Provider InformationDoctor's NameCityPhone NumberEmergency Medical Treatment (must sign)I give Kid Academy, Inc. permission to obtain emergency medical treatment for my child Yes I agreeSignature Sign Here DatePhotography Permission (must sign. Can request no social media)I give Kid Academy, Inc. permission to photograph or videotape my child at Kid Academy Yes I agreeSignature Sign Here DateField Trip PermissionI give my child permission to participate in any field trips with his/her class Yes I agreeSignature Sign Here DateParent Referral If you were referred by a parent of Kid Academy, past or present, please provide their name and child's name belowParent's NameChild's NameSubmit Form
