Christian Academy

- Enrollment Application

HLEP

Higher Learning Christian Academy
Enrollment Application

 

Please fill out this form for an application into one of our centers. Fill out and submit this application for only one child. If you are enrolling more than one child, fill out a separate application for each child.

All required fields will be marked with an *

Desired Start Date*

Your email address*

Child Information *

Child's Name

Birth Date
 
Address

City

State
Zip

Parent Information
Mother *

Mother's Name

Home Phone
Address
City
State
Zip
Mother Work *

Mother's Employer

Work Phone
Ext.
Address

City

State
Zip
Father *

Father's Name

Home Phone
* if same home address as Mother (above) leave blank
Address
City
State
Zip
Father Work *

Father's Employer

Work Phone
Ext.
Address

City

State
Zip

Emergency Contacts - (YOU MUST INDICATE BOTH) *
First Contact *

Name

Relation
Address
City
State
Zip

Home Phone

Work Phone
ext.
Second Contact *

Name

Relation
Address
City
State
Zip
Home Phone
Work Phone
ext.

Medical Information *

Child's Doctor

Phone
Ext.
Address

City

State
Zip
Allergies ( If Child Has No Allergies - Please Indicate"NONE" )

Drug Allergies

Food Allergies

Custody Information

Name of person PROHIBITED from pick up the child:

If non-custodial parent is not included among those persons authorized by the custodial parent to pick up the child, please explain below and forward a copy of appropriate court order.


Authorization for Transportation & Medical Treatment *

I have completed the medical emergency permission form which authorizes the center to seek emergency medical care for my child as deemed necessary by the Director or the director's designee.

Yes

No

Authorization for Walking Trips *

I give permission for my child to participate in walking trips withing the center's neighborhood.

Yes

No