2024 - 2025 ENROLLMENT APPLICATION

2024 - 2025 ENROLLMENT Application
1st Student Name:*

First NameMiddle NameLast Name
1st Student Birth Date:*

MonthDayYear
1st Student Social Security Number: (Required for new students only)*
2nd Student Name:

First NameMiddle NameLast Name
2nd Student Birth Date:

MonthDayYear
2nd Student Social Security Number: (Required for new students only)
3rd Student Name:

First NameMiddle NameLast Name
3rd Student Birth Date:

MonthDayYear
3rd Student Social Security Number:(Required for new students only)
Mother's Name:*

First NameMiddle NameLast Name
Phone Number*
Mobile Number*
Mother's E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employed By:*
Hours of Employment *
Work Number*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:*
If Divorced, Who Has Custody of Child/Children*
Father's Name:*

First NameMiddle NameLast Name
Phone Number*
Mobile Number*
Father's E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employed By:*
Hours of Employment *
Work Number*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Name: (Other than Parent or Doctor)*

First NameMiddle NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Name: (Other than Parent or Doctor)*

First NameMiddle NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person(s) Authorized to Take Child From the Facility:*
PHYSICIAN AND PREFERRED HOSPITAL TO BE USED IN AN EMERGENCY
I understand that in case of an accident or injury to my child, I will be notified as soon as possible. I give permission for my child to receive emergency medical care if deemed necessary. Please use the medical services recommended.
Doctor/Physician Name, Address & Phone Number:*
Preferred Hospital, Address & Phone Number: *
Initials*
Date:*
FIELD TRIPS AND TRANSPORTATION
I do X - if yes* / do not X - if yes* give consent for my child to take part in field trips or excursions with this school facility under proper supervision. It is my understanding that I will be notified when such trips are planned.
AGREEMENTS
A. When my child is ill, I understand and agree that my child may not be accepted for school.   Initials*   Date*

B. I give permission for my child to be transported and treated by a medical facility in case of emergency. (Transportation to a medical facility may be provided by the school.)
   Initials *   Date*

C. I give permission for my family's picture to be put on Christ Tabernacle/Mid-America Preparatory School's Web page. I give permission for my child to be photographed and the photo printed in advertisement materials. (Not required for enrollment)
Initials *   Date*

D. I give permission for the following people to be authorized to pick my child/children up from school and transport them.
First Name*   Last Name*   Area Code*   Phone Number*
First Name*   Last Name*   Area Code*   Phone Number*


Date*
Date*
Initials*
Date:*
STUDENT'S HISTORY
Allergies:*
Please list below & on a separate paper, all of the schools (private or public) that your child has attended in the past:
School Name:*
Dates of Attendance:*
Phone:*
Reason for Leaving:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name:*
Dates of Attendance:*
Phone:*
Reason for Leaving:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School Name:*
Dates of Attendance:*
Phone:*
Reason for Leaving:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Discipline/health concerns we should know about: (Information should be provided by a doctor for any diagnosed conditions.)*
This certifies that my child is, to my knowledge, in good health and free of disabilities that would endanger him/her or other children in the school facility. I give my permission to Mid-America Preparatory School to contact former schools for financial, health, and behavioral references on my child and our family. All of the above information given is true to my knowledge and I agree to abide by the rules of Mid-America Preparatory School.
Father's Signature *

Clear
Father's Name:*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
Mother's Signature*

Clear
Mother's Name:*

First NameMiddle NameLast Name
Date*

MonthDayYear
Date
1st Student's Signature

Clear
1st Student's Name:

First NameMiddle NameLast Name
Date

MonthDayYear
Date
2nd Student's Signature

Clear
2nd Student's Name:

First NameMiddle NameLast Name
Date

MonthDayYear
Date
3rd Student's Signature

Clear
3rd Student's Name:

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Should be Empty:

2024 - 2025 ENROLLMENT Application

PHYSICIAN AND PREFERRED HOSPITAL TO BE USED IN AN EMERGENCY

I understand that in case of an accident or injury to my child, I will be notified as soon as possible. I give permission for my child to receive emergency medical care if deemed necessary. Please use the medical services recommended.

FIELD TRIPS AND TRANSPORTATION

AGREEMENTS

STUDENT'S HISTORY

Please list below & on a separate paper, all of the schools (private or public) that your child has attended in the past: