Registration Form

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1
Thinking CAP Academy
82-66 Austin Street Kew Gardens, NY 11415
Tel: 718-480-3709 • E:mail: [email protected]
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:
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