Learning Center Registration

School Registration
Buena Park Christian Learning Center
Additional documents for registration

Copy of immunization record or signed letter of religious exemption
Student Information
Name

First NameLast Name
M.I.
Birth Date

MonthDayYear
Gender
Email Address
Entry Year
Grade
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 Ended

MonthDayYear
1. I acknowledge that this is a Learning Center with staff that are not credentialed teachers.
2. I confirm that my child does not have an active IEP on file with a public school district.
3. I acknowledge that masks will be optional, but may be required at some events or field trips. I agree to send my child with one daily.
4. I acknowledge that students will be learning standards based curriculum, however there will be a Biblical view in science and other subjects taught.
5. I agree to notify school by texting Mrs Erika at 714-414-7839 or emailing at learningcenterbp@gmail.com when my child is absent.
Parents initials
Date Acknowledged

MonthDayYear
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
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School Registration