New Medina Registration

All registrations are received and reviewed in a first come, first serve basis. Upon filling all open spots, all additional submissions will be added to our waiting list.

Expected Start Date

DayMonthYear

Will you need Extended Care*

Will your child require a school lunch*

School lunches $5.00

First Name*

Last Name*

Gender*

FM

Birth Date*

MonthDayYear

Grade Level entering:*

Current School Name:*

Home Phone*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

Postal CodeCountry

Health Care #

Doctors Name

First NameLast Name

Doctors Phone Number

Area CodePhone Number

Full Name*

First NameLast Name

Home*

Area CodePhone Number

Mobile*

Area CodePhone Number

Work

Area CodePhone Number

E-mail*

Address - Same As Child*

YesNo

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Parent/Guardian 1 Address

Street Address

Street Address Line 2

City

Postal CodeCountry

Full Name*

First NameLast Name

Home*

Area CodePhone Number

Mobile*

Area CodePhone Number

Work

Area CodePhone Number

E-mail*

Address - Same As Childs

YesNo

If your address is different than the childs please fill out the info below. Otherwise move onto the next section.

Address

Street Address

Street Address Line 2

City

Postal CodeCountry

Does your child have a friend or sibling that already attends New Medina?

YesNo

If yes, name and age of friend(s)?

Is your child immunized?*

YesNo

If no, please state why:

Does your child have any allergies?*

YesNo

If yes please list, including any food or drug allergies.

Does your child have any medical conditions?*

Does your child have an IEP or 504 Plan? If yes, please provide a copy.*

Does your child require any medication? If yes, please list these medications.*

Has your child ever been suspended or expelled from any school? Please explain.*

Please list the people authorized to pick up your child.*

Does your child have any siblings?*

If yes, what is their age(s)?

Comments

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal CodeCountry

Home*

Area CodePhone Number

Mobile

Area CodePhone Number

Work

Area CodePhone Number

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal CodeCountry

Home*

Area CodePhone Number

Mobile

Area CodePhone Number

Work

Area CodePhone Number

Has the student had any significant changes to the home environment in the last 6-24 months? If yes, please briefly explain.*

Has the student experienced any form of bullying at any previous school? If yes, please briefly explain.*

Does the child have any challenges surrounding anger and/or temper that we should be aware of? If yes, please briefly explain.*

Have you ever homeschooled/cyberschooled before? If yes, which program/school?*

What attracted your family to New Medina Learning Institute? How do you think this environment will suit your needs?*

When my child is frustrated, this is how he/she responds:*

My child responds well when the following forms of redirection are used:*

My child uses the following ways to communicate most of the time:*

My has the following nighttime routine:*

My child's favorite hobby is:*

My child's favorite foods are:*

My child has the following weekend routine:*

Is there a custody order that we should be aware of? If yes, please provide a copy of the order to the Office.*

New Medina Emergency Clause and Waiver of Liability:

I affirm that the above information is complete and true to the best of my knowledge. I understand that New Medina, its administration, officials, and staff are not responsible for any injuries or loss of property that may occur. In the case of an emergency where I cannot be contacted or reached, I authorize New Medina and the school administration to seek medical attention, transport by public emergency vehicle and/or administer any needed emergency procedures for the registrant. I also authorize my insurance information to be used and I authorize the staff and directors or the insurance company to release any informatiopn required to process the claim. In such case, I understand that I am financially responsible for any care associated with the emergency.

Yes*

Media Release:

By submitting this form, I hereby agree and give my permission for New Medina Learning Institute ("New Medina") and/or partners to record, film,photograph, audiotape or videotape my child(hereinafter collectively referred to as “Works”) and to display, publish or distribute these Works for the purpose of publishing, posting on New Medina's website and posting on social media sites. I hereby waive any right to approve the use of these Works now or in the future, whether the use is known to me or unknown, and I waive any right to any royalties related to the use of these Works. I understand that the Works may appear in electronic form on the internet or in other publications outside of the New Medina's control. I agree that I will not hold New Medina responsible for any harm that may arise from such unauthorized reproduction. I hereby grant permission to New Medina to record my child's likeness and/or voice for use by television, films, radio, or printed media to further the aims of New Medina in related campaigns, magazines articles, booklets, brochures, posters and any other way the organization may see fit. I agree to follow New Medina's Media Release policy set forth in the Student Handbook, should I wish to change my permission hereby granted.

Fee Authorization:

By submitting this form, I hereby authorize New Medina Learning Institute to charge my credit or debit card for a total of $50.00. I understand that payment of this application fee is NON-REFUNDABLE and does not guarantee admission to New Medina Learning Institute. This authorization is valid for a one-time purchase only.

Yes*

My Products*

New Medina Application Fee$50.00

Application fee for new enrollment. NON-REFUNDABLE

Enter coupon

Total $0.00

Credit Card

New Medina Learning Institute Registration Form

Student Information

Primary Parent Contact Information

Secondary Parent Contact Information

Other Infomation

Emergency Contact - Other than Parent/Guardian

Student Profile

Credit Card