Enrollment

Student Information

Date of Birth

Gender

Preferred Date of Enrollment

Last Name

First Name

Middle

Child’s Address

Street

City

Zip

Family Information

Child Lives With

Mother’s Name

Mother’s Address

Mother’s Home Phone:

Employer

Work Address

Father’s Name

Father’s Address

Father’s Home Phone

Employer

Work Address

Medical Information

I hereby grant permission for the staff of this facility to contact the following
medical personnel to obtain emergency medical care if warranted.

Doctor 1

Phone

Address

Doctor 2

Phone

Hospital Preference

Please list allergies, special medical or dietary needs, or other areas of concern

Contacts

Child will be released only to the custodial parent or legal guardian and the persons listed
below. The following people will also be contacted and are authorized to remove the child from the
facility in case of illness, accident, or emergency, if for some reason the custodial parent or legal
guardian cannot be reached

Contact Name 1

Address

Work Phone Number

Home Phone Number

Cell Phone Number

Contact Name 2

Address

Work Phone Number

Home Phone Number

Cell Phone Number

Contact Name 3

Address

Work Phone Number

Home Phone Number

Cell Phone Number

Custody

Mother Father Both Other

Helpful Information About Child

By entering your name below, you verify that you have received the above items and that all information on this enrollment form is complete and accurate

Full Name

Today’s Date

Contacts

Custody

The Academy at Ellison Lakes Kennesaw