Childs Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Male
Male
Female
T-Shirt Size
*
Previous School Name
*
List any special problems that your child may have such as allergies, existing illness, previous serious illness, injuries during the past 12 months, medication prescribed for long-term use and any other information that the staff should know:
Fathers Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Mothers Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Emergency Contact 1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Emergency Contact 2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
I Authorize my child to leave school with the following people. (Include Phone Numbers)
Current Church
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Pastors Name
First Name
Last Name
Please check whether you give consent / do not give consent to your child being TRANSPORTED off-campus and supervised by school employees for emergency care and field trips.
Yes
No
Please check whether you give consent / do not give consent your child to participate in WATER ACTIVITIES. (Children Under 5 years old are not taken to off-campus swimming pools.)
Yes
No
I give consent for E3 Academy to secure any and all necessary emergency medical care for my child. In the event that I cannot be reached, I authorize the person in charge to take my child to: (please include address and phone number of facility.)
Yes
No
Name Of Facility
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My/our acknowledgement below indicates that the information provided on this form is true and accurate. I / we agree to provide an up-to-date physician's immunization / hearing screening record, a copy of the student's birth certificate, and completed enrollment forms prior to the student's first day of attendance. I / we also affirm that we have received a copy and are in agreement with the school's operational policies.
Yes
No
Submit
Should be Empty: