Little Flower Family Discipleship Academy Registration
For children in Grades Pre K - 5. Please have registrations submitted by September 1st, 2024
Father's Name
First Name
Last Name
Mother's Name
First Name
Last Name
Primary Email for Communications
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Family Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Relationship to Child
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child 1 Name
*
First Name
Last Name
Child 1 Gender
*
Female
Male
Child 1 Grade
*
Child 1 Birth Date
*
-
Month
-
Day
Year
Date
Does your child have any allergies or medical issues? If so, please describe here with any specific instructions:
What techniques are most successful for your child in the case of behavior management and/or conflict? (a fidget toy, having an adult nearby, leaving the space to decompress, etc)
Add more children?
Please Select
Yes
No
Child 2 Name
First Name
Last Name
Child 2 Gender
Female
Male
Child 2 Grade
Child 2 Birthday
-
Month
-
Day
Year
Date
Does your child have any allergies or medical issues? If so, please describe here with any specific instructions:
What techniques are most successful for your child in the case of behavior management and/or conflict? (a fidget toy, having an adult nearby, leaving the space to decompress, etc)
Add more children?
Please Select
Yes
No
Child 3 Name
First Name
Last Name
Child 3 Gender
Female
Male
Child 3 Grade
Child 3 Birthday
-
Month
-
Day
Year
Date
Does your child have any allergies or medical issues? If so, please describe here with any specific instructions:
What techniques are most successful for your child in the case of behavior management and/or conflict? (a fidget toy, having an adult nearby, leaving the space to decompress, etc)
Add more children?
Please Select
Yes
No
Child 4 Name
First Name
Last Name
Child 4 Gender
Female
Male
Child 4 Grade
Child 4 Birthday
-
Month
-
Day
Year
Date
Add more children?
Please Select
Yes
No
Does your child have any allergies or medical issues? If so, please describe here with any specific instructions:
What techniques are most successful for your child in the case of behavior management and/or conflict? (a fidget toy, having an adult nearby, leaving the space to decompress, etc)
Child 5 Name
First Name
Last Name
Child 5 Gender
Female
Male
Child 5 Grade
Child 5 Birthday
-
Month
-
Day
Year
Date
Does your child have any allergies or medical issues? If so, please describe here with any specific instructions:
What techniques are most successful for your child in the case of behavior management and/or conflict? (a fidget toy, having an adult nearby, leaving the space to decompress, etc)
Photo Release: Do you give permission to Little Flower to use pictures of your child(ren) in any future promotional materials, including but not limited to printed material, social media, videos, etc.?
*
Please Select
Yes
No
I GRANT TO CONSENT FOR MEDICAL CARE. In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by a licensed physician or medical professional; and (2) the transfer of my child to any hospital reasonably accessible. This authorization does not cover major surgery unless opinions of two licensed physicians, concurring in the necessity for surgery, are obtained prior to the performance of such surgery. *Please note that by selecting "Yes" this pertains to all children mentioned in this form. If specifications for certain children are necessary, please denote them below. By selecting "No" this pertains to all children mentioned in this form. If specifications for certain children are necessary, please denote them below.
*
Please Select
Yes For All Children
No
*Please note that this mostly pertains to 2nd Grade when they have their second meeting on the 3rd Sunday of each month. During FDA, parents will be notified of any emergencies and can make the proper calls for medical needs.
If you have specific needs for the Consent for Medical Care with your children please specify. (ex. Yes for this child, but no for this child, or N/A if you have no specifications.):
*
Signature
*
Submit
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