Parent/Guardian #1 Information *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #2 Information

If not applicable, further info may be required

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Address

If different from Parent/Guardian #1

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Information *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Homeschooler's Program Schedule *

Monday-Tuesday

Thursday-Friday

Before School Program *

8:00 a.m. to 9:00 a.m. (included in program)

Yes, I would like to sign up for the before school program

No, I do not require before care

Unsure for now

After School Program *

3:30 p.m. to 5:30 p.m. (extra cost) Occasional after care cost is $15/day and invoices for days used are sent at the end of each month.

Yes, I would like to sign up for occasional after care

Yes, I would like to sign up for full time after care

No, I do not require after care

Unsure for now

School Directory *

Parent authorizes the School to place family information, including name(s), email address(es), and telephone numbers of Parent, Student in a directory of students to be available to School families. Parent acknowledges that this directory and the information therein is not to be used for commercial use and is not to be distributed to any person other than another School family with parent permission.

Yes, I authorize the School to place family contact information on the School directory.

No, I do not authorize the School to place family contact information on School directory.

Health History *

Are your child's immunizations up to date?

Yes

No

Unsure

Immunization Exemption

Other

Has the student had the following common childhood illnesses? *

Chickenpox

Measles

Whopping Cough

Other

None of the above

Is the student prone to: *

Ear Infections

Headache

Upset Stomach

Colds

Sore Throat

Other

None of the above

Does the student have any speech, hearing or visual problems? *

Yes

No

Unsure

Allergies *

Please indicate any food, environment, or medical allergies the student has.

Peanuts

Other Nuts and Seeds

Citrus Fruit

Cow's Milk

Yogurt

Other Dairy

Corn

Oats

Wheat

Other Grains

Yeast

Egg Yolks

Egg Whites

Soy Foods

Fish

Shell Fish

Cats/Dogs/other animals

Pollen

Bee Stings

Penicillin

Latex

Other

None of the above

Does the student have diagnosed or suspected neurodivergence? (dyslexia, dysgraphia, ADHD, etc) *

Yes

No

Does the student have or has had in the past, an IEP or other service plan in place? *

Yes

No

Does the student require any medication or other medical service while at school? *

Yes

No

Photos and Images *

The Parent agrees to allow the Student’s, photograph, voice, or image to be used by the School for use in the School’s publications, promotion materials, social networks, and website, without compensation and without prior notice. Parent also allows Student to be interviewed by the media on campus or at school-related events. Parent releases and holds the School harmless from any liability stemming from the use of the Student’s, photograph, voice, or image.

Yes

No

Program Fees Payment Plan Options *

Plan A - Deposit + 2 payments

Plan B - Deposit + 4 payments

Plan C - Deposit + 10 payments

Full-payment by June 15th (3% discount)