STUDENT ENROLLMENT FORM 20152016
LIONS MATHEMATICS & SCIENCE CHRISTIAN ACADEMY
□PreK 3
□PreK 4
□Kindergarten □1st Grade □2nd Grade □3rd Grade □4th Grade □5thGrade □6thGrade
□Extended Care (Lions’ Academy Primary Students Only) □Enrichment Program (Public School Students Only)
Please select enrollment program: 2015-2016 Term
Student Information
Last Name
First Name
Address
Home Phone
Street _____________________________City ___________________________
Number of Siblings
Birth date
Ethnic Code
(circle one)
Age
Hispanic
White
Gender:
African American
Male
Multi-Racial
Zip __________________
Female
Asian/Pacific Islander
Native American
Parent/Guardian Information
Mother/Guardian
Name
Relationship to child:
Reside with
child:
YES
NO
Address
Email Address
Employer
Location of
Employment
Highest Level of
Education
Father/Guardian
Name
High School
GED
Work Phone
Cell Phone
College Major
Advanced Degree
Relationship to child:
Reside with
child:
YES
Address
Email Address
Employer
Location of
Employment
Highest Level of
Education
1
High School
GED
Work Phone
Cell Phone
College Major
Advanced Degree
NO
STUDENT ENROLLMENT FORM 20152016
LIONS MATHEMATICS & SCIENCE CHRISTIAN ACADEMY
Calling Post Information
Please provide the number that you would like for Lions to call for school closings or to provide emergency information.
Emergency Contact Information
Doctor Name
Phone
Date of Last Checkup
Dentist Name
Phone
Date of Last Checkup
Insurance Company
Policy#
Allergies
YES
NO
List
Allergies
Medications
YES
NO
List
Medications
Emergency Names & Numbers
List three people who are available to pick up your child if she/he becomes ill.
*minimum of two required
Name
Home#
Work#
Cell#
Home#
Work#
Cell#
Home#
Work#
Cell#
Relationship to child
Name
Relationship to child
Name
Relationship to child
_______________________________________
Parent or Guardian Signature(s)
_______________________________________
Parent or Guardian Signature(s)
2
__________________
Date
__________________
Date