Academic Cultural Enrichment

Academic Cultural Enrichment - ACE

After-school and Summer and other Year Round Camps Program
ACE PROGRAM REGISTRATION FORM
Please note that upon completion and submission of this registration form, the following documents must be brought to the school office to complete your childs file.

• Original Certified Birth Certificate
• Current Immunization Form
• Current Proof of Residence (ex. power, water or gas bill)
• Other - You will be asked to complete a set of waivers and a photo release forms.
- Please Note: We will provide "Distant Learning"; "Full Day" and Saturday Classes" please circle and indicate below the electronice device your child will use during the distant learning sessions:
- LAPTOP; IPAD; IPHONE; SMART TV or other devices
Student Information
Name*

First NameLast Name
Birth Date *

MonthDayYear
Date
Gender*
Ethnicity*
Email Address*
example@example.com
Entry Year*
Grade*
Semester*
Have you previously applied to or attended this school?*

YesNo
If yes, what year?*
Current Residence Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Primary Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 1
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.*

Previous School 1
School Name*
City*
State*
Date Started*

MonthDayYear
Date
Date Ended*

MonthDayYear
Date
Previous School 2
School Name
City
State
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Previous School 3
School Name
City
State
Date Started

MonthDayYear
Date
Date Ended

MonthDayYear
Date
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. If none please type N/A or None.*
Should be Empty:

Academic Cultural Enrichment - ACE