School Registration

School Registration
Kingdom Academy
Additional documents for registration

Bring or mail in this registration form and the following documentation to the school office.

• Original Certified Birth Certificate
• Current Immunization Record
• Current Physical (When Applicable)

*Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.

*Note: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent, of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities.
Student Information
Name

First NameMiddle NameLast Name
Nickname
Chronic Physical Problems/Pertinent Developmental Information
Birth Date

MonthDayYear
Gender
Ethnicity
Email Address
Entry Year
Current Grade
Current Age
Semester
Have you previously applied to or attended this school?

YesNo
If yes, what year?
Current Student 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
Father's Information
Father’s Name

First NameLast Name
Father’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father’s Place of Employment
Father’s Cell Phone
Please enter a valid phone number.
Father’s Home Phone
Please enter a valid phone number.
Father’s Business Phone
Please enter a valid phone number.
Person(s) or Agency Having Legal Custody of Child
Mother's Information
Mother’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother’s Place of Employment
Mother’s Cell Phone
Please enter a valid phone number.
Mother’s Home Phone
Please enter a valid phone number.
Mother’s Business Phone
Please enter a valid phone number.

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Physician
Name

First NameLast Name
Phone Number

Area CodePhone Number
Allergies or Intolerance to Food
Please list any of the following: Current medications or chronic health concerns.
Provide Any Additional Information on Allergies, Medications or Action to Take in an Emergency:
Person(s) NOT Authorized to Pick Up Child:

Previous School 1
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 2
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 3
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Notes
Please inform the office of any other vital information you think they may need to know regarding your child. Thank you.
Agreements

1. The child day center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so requested by the center.

2. The parent(s)/guardian(s) authorize the child day center to obtain immediate medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately.

**(If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that state the objection and the reason for the objection.)
Signature

Clear
Date of Signature

MonthDayYear
Date
Additional documents for registration

Bring or mail in this registration form and the following documentation to the school office.

• Original Certified Birth Certificate
• Current Immunization Record
• Current Physical (When Applicable)

*Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child.

*Note: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent, of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities.
Should be Empty: