Application

Medical Information
Please list any medical issues your child may have, such allergies, existing illness,
previous serious illness, hospitalization, injuries during the past 12 months, any
medication prescribed for long-term continuous use, and any other information of which the staff should be aware. Children with chronic illnesses such as severe allergies or asthma, or those children with special circumstances, must have an individualized health care action plan on file from the child’s medical provider. Food allergy information will be shared with parents who provide classroom snacks so snacks containing those foods or ingredients will not be served in class. All allergies listed must have an action plan on file. If your child does not have any medical conditions or allergies, please indicate "None."
Does the student have any medical conditions?*
If yes, please explain
Does the student have any allergies?*
If yes, please explain
Doctor*
Doctor's Phone Number*
Please enter a valid phone number.
Doctor's Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist*
Dentist Phone Number*
Please enter a valid phone number.
Doctor's Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code

My signature below confirms that the information in this enrollment packet is
accurate, complete and honestly presented. I understand that providing any false
information may result in my child’s enrollment or re-enrollment.
Signature

Clear
Date

MonthDayYear
Date
Printed Name

First NameLast Name
Enrollment Application is complete when Allegiance Academy has received:
Student Records
Standardized Test Scores or Norm-referenced scores
Transcripts
Parent Questionnaire
Student Essays
Health Records
Supporting Documentation
Should be Empty:

Student Information