Crystal Castle Learning Center

Crystal Castle Learning Center

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Student's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Age*
Gender*

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Parent/Guardian's Name
Parent/Guardian's Name
Language spoken at home
Permanent Contact Details
Residence/ Address*

Street Address

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Mailing Address

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Emergency Contact Info

Street Address

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CityState / Province

Postal / Zip CodeCountry
Parent's Phone*
Parent's Alt. Phone
Emergency Contact Phone Number

Area CodePhone Number
Alternate Emergency Phone Number

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Email*
Does student suffer from any medical condition/disability that may affect his/her studies?*

NoYes
If yes, please specify from the following*

HearingLearningMobilityVisualMedicalOther
Does student have any physical limitations? Explain.
Does your student have siblings in or out of this school?
How did you hear about us?*

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Any Known Allergies*

How does your child learn best?
What are your child's strengths and weaknesses?
What should we know about your student?
Do you agree to have your child comply with all current CDC guidelines for Covid 19 for the safety of all staff and students?

Supporting Documents
Copy of Parent's Government Issued I.D. or License

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Anything else we should know about your student/family?
Declaration
For an applicant under the age of 18.*

I, the parent/guardian of the applicant hereby consent to this application for study
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Permanent Contact Details