Student Application

Student Application

Section 1
Please Choose One*

Full Time: 5 Full DaysPart Time: 3 Full DaysPart Time: 2 Full DaysDrop-In
Child's Full Name*

First NameLast Name
Child's Age*
Child's Birthday*

MonthDayYear
Date
Contact 1 Full Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Contact 2 Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com

Emergency Contact Form

Section 2
Contact 1 Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Contact 2 Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail
example@example.com

For Medical Assistance

Section 3
Doctor's Name*
Phone Number*
Medical ID Number*
Dentist's Name
Phone Number
Medical ID Number

Allergies & Medications

Section 4
Allergies
Medication Taken
Frequency
Refrigerated

YesNo
Medication Taken
Frequency
Refrigerated

YesNo

Bed Time
Foods to Avoid
Potty Trained

YesNo
Started Potty Training? Date
Naps

YesNo

Photo Release Form

Section 5
PLA PHOTO RELEASE FORM

This form is for the legal release of photos of your minor child. Parents/Guardians please sign below. This form is to authorize Panoramic Learning Academy, LLC to publish photos taken of the following person/s to be used in all media outlets and web content.

I am aware that this form releases Panoramic Learning Academy, LLC from any liabilities or claims. I fully understand the terms and conditions under this agreement.

I hereby authorize Panoramic Learning Academy, LLC to publish photos taken of my minor for the company's online and print marketing materials.
Signature*

Clear
Should be Empty: