1 Thinking CAP Academy 82-66 Austin Street Kew Gardens, NY 11415 Tel: 718-480-3709 • E:mail: thinkingcapny@gmail.com Name of participant: _______________________________________________________ Checklist: o Registration Form o Authorization/Pick-up Form o Medical o CHILD & ADOLESCENT HEALTH EXAMINATION FORM o Education Background o Registration fee o Acceptable forms of payment: o Liability Form o Photo Release Form Parent Signature: Date: Parent Initial: 2 Registration Form Name of child: ________________________________________ DOB: ________________________________________ Mother/guardian full name: _________________________________________ Home phone: _____________________ Cell phone: ______________________ Work phone: _____________________ E-mail: _________________________ Employer’s name and address: ________________________________________ Father/guardian full name: _________________________________________ Home phone: _____________________ Cell phone: ______________________ Work phone: ______________________ E-mail: ________________________ Employer’s name and address: ________________________________________ Language(s) spoken at home: ________________________________________ Parent Initial: 3 Authorization Form If you authorize another adult (over 18) to pick up your child, please give or email a copy of their identification (ex. driver license, passport, state ID). Special exceptions can be made by written consent. Please have them present their ID upon arrival. Adults Authorized to pick up your child (other than parent/guardian): 1. Name: ______________________________________________________________ a. Relationship to child: b. Cell phone: 2. Name: ______________________________________________________________ a. Relationship to child: b. Cell phone: Please provide 2 emergency contact names and phone numbers: 1. Name: ______________________________________________________________ a. Relationship to child: b. Cell phone: 2. Name: ______________________________________________________________ a. Relationship to child: b. Cell phone: Parent Initial: 4 Medical Medical information Physician’s name: ______________________________________________________________ Physician’s phone number: ________________________________________________________ Does your child have any allergies? Food: ______________________________________________________________ Medication: ______________________________________________________________ Type of allergy medicine (ex. Benadryl, Epi-pen): ______________________________________________________________ If your child has completed the CHILD & ADOLESCENT HEALTH EXAMINATION FORM NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION in the past 6 months, please submit a copy of the form. If your child has not been to his/her physician in the past 6 months, please complete the CHILD & ADOLESCENT HEALTH EXAMINATION FORM NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION and submit a copy to ThinkingCAP Academy. ALL MEDICAL FORMS HAVE TO BE SUBMITTED BEFORE YOUR CHILD STARTS CLASSES/TUTORING. YOU CAN EMAIL IT OR BRING IT WITH THE REST OF THE APPLICATION. Parent Initial: 5 Education If you child attended more than one school, please list all the different schools she/he attended. If your child didn’t attend nursery or preschool, write N/A. Name and location of nursery: ______________________________________________________________ Name and location of preschool: ______________________________________________________________ Name and location of kindergarten: ______________________________________________________________ Name and location of elementary school: ______________________________________________________________ Name and location of middle school: ______________________________________________________________ Name and location of junior high school: ______________________________________________________________ Name and location of high school: If your child, attended more than one school in one school year, please explain why they have been to more than one school. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Parent Initial: 6 Education (cont’d) Does your child have an Individualized Education Plan (IEP)? Circle one. YES/NO Does your child have/take a language class at school or outside of school? List languages(s) including American Sign Language. ______________________________________________________________ If your child is under the age of 5, please list what skills your child has learned. (ex. Able to write their own name, count to 20, etc.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Leave the areas below blank if your child is not enrolled in school yet. Is your child enrolled in a Gifted and Talented Program? Circle one. YES/NO Has your child taken the Otis-Lennon School Ability Test (OLSAT) OR the Naglieri Nonverbal Ability Test (NNAT®2)? Circle one. YES/NO What is your child’s strongest subject area? ______________________________________________________________ What subject area would you like to see improvement in? ______________________________________________________________ Parent Initial: 7 Education (cont’d) What technological tools/software/application does your child use at school and at home? (ex. Gaming software, LeapFrog, Microsoft Word, Neopets) ______________________________________________________________ What technological tools/software/application would you like your child to learn? ______________________________________________________________ Does your child have a preferred study method? (ex. Breaks for 5 minutes after every 25 minutes, flashcards or using an Ipad to gather information) ______________________________________________________________ If you have any other comments or questions to help us make it a better learning environment for your child, please feel free to use this space below to explain. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Parent Initial: