COSLA PreK Application 2023-2024

CIRCLES OF SUCCESS LEARNING ACADEMY-PREK REGISTRATION FORM-2023/2024
PERSON COMPLETING THIS FORM
CIRCLES OF SUCCESS LEARNING ACADEMY
SCHOOL NAME
(Please print name exactly as it appears on the birth certificate
Name

CHILD'S FIRST NAMECHILD'S LAST NAME
CHILD'S MIDDLE NAME
NAME SUFFIX
CHILD'S SOCIAL SECURITY#
DATE OF BIRTH

MonthDayYear
IF BIRTHDAY IS AFTER 8/15/2019, YOUR CHILD IS INELIGIBLE FOR THE 2023-2024 SCHOOL YEAR
SEX:
Address

HOME ADDRESS

Street Address Line 2

CityState / Province

Postal / Zip CodeCOUNTY
CITY
STATE
TELEPHONE
If the Student is transferring from another Pre-K, please provide the following:
Previous School Name
Last Date in Attendance

MonthDayYear
Date
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 LAST NAME
FIRST
MIDDLE INITIAL
Home Address (If different from child)
City
State
Zip
Cell Phone: ( )
Cell Phone
Email Address
example@example.com
Work Phone
Address
City
State
Zip
Parent/Guardian #2 LAST NAME
FIRST
MIDDLE INITIAL
Home Address (If different from child)
City
State
Zip
Home Phone
Email Address
example@example.com
Work Phone
Address
City
State
Zip
EMERGENCY CONTACT INFORMATION(Persons to contact in the event that either parent/guardian cannot be
NAME
RELATIONSHIP
CELL PHONE
ALTERNATE PHONE
EMAIL
1.
2.
I verify the above information to be correct, and I understand that completion of this form does not guarantee placement in a Pre-K class. If my child is placed in COSLA's Pre-K Program, I agree that my child will attend the program for the required number of hours and days as prescribed by the Tennessee Department of Education and outlined by COSLA where my child is enrolled. I understand that failure to comply with these attendance requirements could result in disenrollment. I understand that I cannot register my child without appropriate age documentation. I have attached a copy of appropriate age documentation to this registration form.
Signature Parent/Guardian
DATE

MonthDayYear
Date
CHILD MAINTENANCE
CHILD'S LIVING ARRANGEMENTS

BOTH PARENTSMOTHERFATHER[ ]OTHER]OTHER
BOTH PARENTSMOTHER

[ ]BOTH PARENTS [ ]MOTHER [ ]FATHER[ ]OTHERCHILD'S LEGAL GUARDIAN:]OTHER
CHILD'S LEGAL GUARDIAN:
THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE RELATIONSHIPCELL PHONE FOLLOWING: NAME ADDRESS
NAME
CHILD'S PHYSICIAN OR CLINIC'S NAME (CHILD'S PRIMARY HEALTH SOURCE)
DATE OF LAST FULL HEALTH SCREENING

MonthDayYear
Date
PHONE: ( )
MY CHILD HAS THE FOLLOWING SPECIAL NEED(S)/ALLERGIES
THE FOLLOWING SPECIAL ACCOMMODATION(S) MAY BE REQUIRED TO MOST EFFECTIVELY MEET MY CHILD'S NEEDS WHILE AT THIS ACADEMY
MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG-TERM CONTINUOUS USE AND/OR
HAS THE FOLLOWING PRE-EXISTING ALLERGIES, ILLNESS, OR HEALTH CONCERNS:
MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG TERM CONTINUOUS USE AND/OR HAS THE FOLLOWING PRE EXISTING ALLERGIES, ILLNESS, OR HEALTH CONCERNS
NOTE: The following documents will be needed before enrollment is granted

Parent ID (Driver's License)

*Two Proofs of Residence - see acceptable proofs below

Certified (state stamped) Birth Certificate (Not mother's copy)

TN Certificate of Immunization (current)

Proof of Physical (current)

Proof of Income (W2 Form)

Your child must be 4 years of age on or before August 15, 2019
Acceptable Proofs of Residence include

Valid Driver's License

Current MLGW Bill

Municipal Water Bill

Lease or Rental Agreement

Public Assistance/government benefits letter

Real Estate Tax Receipt

Mortgage Statement or Deed

Military Housing Agreement
Pre-K Student Registration Checklist (for school use only)

TWO proofs of residence (please indicate the two (2) provided)

Public Assistance/government benefits letter
TWO Proofs of Residence (Please indicate the two (2) provided)

Valid Driver’s licenseCurrent MLGW billMunicipal water billLease or Rental AgreementPublic Assistance/government benefits letterReal estate tax receiptMortgage statement or deedMilitary housing agreement
File Upload

Cancelof
Other Required Documents:

Parent IDCertified Birth Certificate (Mother’s copy will not be accepted)Student Social Security CardProof of Immunization record on Tennessee School FormUpdated Physical (signed by physician)Proof of Income (W2)
File Upload

Cancelof
I verify the above information to be correct and true. I hereby grant permission for the information provided in the preceding Registration Form to be distributed to COSLA's Pre-K providers, and certain agencies or those entities contracted by the Academy's Pre-K providers, which shall include, but not be limited to, the Tennessee Department of Education, and colleges/universities.
SIGNATURE (Parent/Guardian)
DATE

MonthDayYear
Date
Should be Empty:

CIRCLES OF SUCCESS LEARNING ACADEMY-PREK REGISTRATION FORM-2023/2024

PARENT/GUARDIAN INFORMATION

RELATIONSHIP

ALTERNATE PHONE

EMAIL

CHILD MAINTENANCE

CHILD'S LEGAL GUARDIAN:

THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE RELATIONSHIPCELL PHONE FOLLOWING: NAME ADDRESS

MY CHILD IS CURRENTLY ON MEDICATION(S) PRESCRIBED FOR LONG-TERM CONTINUOUS USE AND/OR

HAS THE FOLLOWING PRE-EXISTING ALLERGIES, ILLNESS, OR HEALTH CONCERNS: