Taking education to new heights
Application for Enrollment
Instructions: Please complete all sections of the application. A $50 non-refunded ($25 each additional
child) application fee is required with completed application.
Date of application_________________________
Applying Grade __________________________
Date enrollment is to begin __________________
School year _______________________________
Preschool schedule: Days____________________
Hours____________________________________
STUDENT INFORMATION
Full Name _______________________________________
Name called _______________________________
Date of Birth
Social Security # ___________________________
Male
______________________
Age _______
Female
Student’s Address _____________________________________________________________________________
Street
City
State ________________________________
Zip __________
Last School Attended ___________________________________
Home Phone # _______________________
Grade ______
Date attended ________
Is the student currently receiving tuition assistance from a scholarship program?
Yes
No
If yes, what scholarship? _______________________________________________________________________
Race/Ethnic Origin:
Hispanic
Asian or Pacific Islander
White, not of Hispanic origin
Black, not of Hispanic origin
Other: please explain ____________________________________________
PARENT/GUARDIAN INFORMATION
Father’s/Guardian Information __________________________________________________________________
First
Middle
Last
Home Address ________________________________________________________________________________
Street
Home Phone __________________
City
State
Work Phone _______________________
Employer ___________________________________
Zip
Cell Phone ______________
Occupation ___________________________________
Email Address ________________________________________________________________________________
Oxford Preparatory Academy * 5454 Arlington Expressway * Jacksonville, FL 32211 * 904-638-8803
www.oxfordpreparatoryacademy.org
1
Mother’s/Guardian Information _________________________________________________________________
First
Middle
Last
Home Address ________________________________________________________________________________
Street
City
Home Phone __________________
State
Work Phone _______________________
Employer ____________________________________
Zip
Cell Phone ______________
Occupation ___________________________________
Email Address ________________________________________________________________________________
Student parents:
married
separated
divorced
single
widowed
If separated or divorced please provide custodial details that our staff may need to know.
_________________________________________________________________________________
(Example: Joint custody, sole custody, etc.)
With whom does the student reside? _____________________________________________________________
EMERGENCY CONTACTS/ALTERNATE PICKUPS
Please list names of alternate emergency contact and pick up. These individuals would be contacted in the event of
an emergency when parents cannot be contacted
Name
Address
Relation to Student
Phone
Name
Address
Relation to Student
Phone
Name
Address
Relation to Student
Phone
Who may NOT sign out the student? _______________________________________________________________
SIBLING OF APPLICANT
Please list, if any, siblings that are currently enrolled or are applicants at Oxford Preparatory Academy.
Enrolled/Applicant
Student Name
Grade
Student Name
Grade
Student Name
Grade
Circle One
Enrolled/Applicant
Circle One
Enrolled/Applicant
Circle One
ACADEMIC HISTORY
List other schools your child has attended. If you are applying for VPK or Kindergarten list preschool attended.
Please list most recent school first.
School
Address
City
State
Grade
School
Address
City
State
Grade
School
Address
City
State
Grade
Oxford Preparatory Academy * 5454 Arlington Expressway * Jacksonville, FL 32211 * 904-638-8803
www.oxfordpreparatoryacademy.org
2
MEDICAL INFORMATION
Medical Authorization
In my absence or in the absence of an authorized parent or guardian of _________________________________ , I
hereby authorized Oxford Preparatory Academy, its agents, employees, or designees to administer first aid and to
obtain consent on behalf of the participant and participant’s parent or guardians to administer any emergency first
aid or medical care by any physician, hospital, or medical attendant which is deemed necessary or expedient by said
physician, hospital, or medical attendant as a result of involvement in activities at Oxford Preparatory Academy or
while on field trips. I agree to abide and be bound by such decisions and consents as if made by me and do assume
full responsibility for and agree to pay all expenses of such care.
The name of my health insurance company is ________________________________________________________
Policy number __________________________
I further authorize any physician, hospital, or medical attendant to receive full and complete medical reports of
information deemed necessary by them with respect to the treatment of my child. Execution of this document shall
operate as an authorization for such person(s) to receive any medical information, which they require.
The medical authorization contained within this form will be valid and usable by Oxford Preparatory Academy
during such periods of time as my child is enrolled at Oxford Preparatory Academy and this authorization shall
remain valid unless revoked by me in writing.
Parent or Guardian ______________________________________ Date __________________________________
Family doctor _________________________________________
Office number __________________________
Any physical difficulties or other medical conditions:
_____________________________________________________________________________________________
Is your child taking medication?
Yes
No
If yes, name the medication and for what condition is it used? ___________________________________________
____________________________________________________________________________________________
Does the student have any known mental, emotional, or physical conditions that would limit their participation
and/or alter our care for the student? If yes, please explain. (Examples: hearing, vision, asthma, autism, ADHD,
etc.)
_____________________________________________________________________________________________
_________________________________________________________________________________
Please list allergies, special medical or dietary needs or other areas of concern:
_____________________________________________________________________________________________
_________________________________________________________________________________
Oxford Preparatory Academy * 5454 Arlington Expressway * Jacksonville, FL 32211 * 904-638-8803
www.oxfordpreparatoryacademy.org
3
GENERAL INFORMATION
Has your child either repeated a grade or skipped a grade in a previous school? (Please specify and state which
academic year)___________________________________________________________
Has your child ever been tested for a Learning Disability? (If yes, please attach report and give general results of the
test)
_____________________________________________________________________________________________
_________________________________________________________________________________
How did you find out about our program? ___________________________________________________
Additional Service Options (will be an additional charge)
Please check the following services you will require:
Before Care
After Care
Tutoring - What Subjects?
I have provided accurate information to the best of my knowledge. I understand that by providing false information
it may have an effect on my child’s class placement. I also understand that this application is just a step in
completing the enrollment process and does not guarantee a slot for my child. Your signature indicates that you
understand, agree and support the program and practices as set forth in the student handbook of The Oxford
Preparatory Academy.
Signature _____________________________________________ Date ___________________________________
Signature _____________________________________________ Date ___________________________________
Non Discriminatory Policy:
Oxford Preparatory Academy does not discriminate against students of any ethnic origin in its educational
or admissions policies, scholarships, athletic programs or any other school administrated programs.
Office Use Only:
Student Identification # __________________________
Current Tuition Assistance Program ________________________
Matrix Score _________________
Confirmation # _______________________
Application Fee Paid ___________
Scheduled Interview Date _______________________
Registration Fee Paid ___________
Entrance Testing Date ___________________
Oxford Preparatory Academy admits students of any race, color, national and ethnic orgin.
Oxford Preparatory Academy * 5454 Arlington Expressway * Jacksonville, FL 32211 * 904-638-8803
www.oxfordpreparatoryacademy.org
4