ATO Academy Student Application

Student Application

This application begins the enrollment process. It does not register a student.
At The Outlet Academy Inc.
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 NameLast Name
Middle NameNickname/Preferred to be Called
Birth Date

MonthDayYear
Gender
Ethnicity
Email Address
Entry Year
Grade
Semester
Fall/Spring and Year
Have you previously applied to or attended this school?

YesNo
If yes, what year?
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
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 in the event of an emergency. Thank you.
Should be Empty: