School Registration
QEAC Tutoring Centre
Additional documents for registration Bring this registration form and the following documentation to the school office. • Original Certified Birth Certificate• Original Social Security Card• Current Immunization Form• Current Proofs of Residence (ex. power, water or gas bill)• Other
Student Information
Name
First Name
Last Name
ID Number
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Gender
Please Select
Male
Female
Ethnicity
Please Select
African American
Hispanic/Latino
Asian
Caucasian
Native American/Alaskan
Hawaiian/Pacific Islander
Middle Eastern
Prefer not to answer
Other
Email Address
Entry Year
Grade
Semester
Have you previously applied to or attended this school?
Yes
No
If yes, what year?
Current Residence Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Primary Residence Information (if different from above)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Residence Information (if different from above)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Emergency Contact 1
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Emergency Contact 2
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Physician and Medical Information
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Preferred Hospital
Medical Aid
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Back
Next
Previous School 1
School Name
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date Started
-
Month
-
Day
Year
Date Picker Icon
Date Ended
-
Month
-
Day
Year
Date Picker Icon
Previous School 2
School Name
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date Started
-
Month
-
Day
Year
Date Picker Icon
Date Ended
-
Month
-
Day
Year
Date Picker Icon
Previous School 3
School Name
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date Started
-
Month
-
Day
Year
Date Picker Icon
Date Ended
-
Month
-
Day
Year
Date Picker Icon
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.
Submit
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