Dragon Academy Enrollment Form

Dragon Academy Enrollment Form

Please fill out all information
Application Date

MonthDayYear
Date
Enrollment Date

MonthDayYear
Date
Withdrawal Date

MonthDayYear
Date
Full name of child*

First NameMiddle NameLast Name
Gender

BoyGirl
Date of birth*

MonthDayYear
Date
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Identify the person with whom the child lives:

Both ParentsMotherFatherGuardianOther
If Other is selected please specify:
Name of Child's Doctor*
Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor's Phone Number
Please enter a valid phone number.
Name of Child's Dentist
Dentist's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist Phone Number
Please enter a valid phone number.
Child's Medical Insurance Carrier
Policy Number*
Child-Special Information
Immunizations must be provided within 30 days (or signed affidavit)

MonthDayYear
Date of Expiration
Does your child have any known allergies? if so, please list here or answer with none*
Does your child have any special needs or accommodations required? *
Does your child have any chronic illnesses/conditions (i.e. diabetes, asthma, seizures, drug allergies) if so, explain*
Is your child on any medication prescribed for long-term use? Please explain below*
Does your child have any special diet restrictions? (a letter from a doctor or written statement for religious beliefs is needed)*
Please provide any information concerning your child which may be helpful in his/her experience at school and in a group setting (such as play, eating, and sleeping habits, fears, likes and dislikes)*
Parent/Guardian Information
Guardian #1*

First NameLast Name
Guardian #1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian #1 Home Phone #*
Please enter a valid phone number.
Guardian #1 Cell Phone Number*
Please enter a valid phone number.
Guardian #1 Email Address*
example@example.com
Guardian #1 Occupation*
Guardian #1 Employer*
Guardian #1 Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian #1 Work Phone Number*
Please enter a valid phone number.
Guardian #2

First NameLast Name
Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian #2 Home Phone
Please enter a valid phone number.
Guardian #2 Cell Phone
Please enter a valid phone number.
Guardian #2 Email Address
example@example.com
Guardian #2 Occupation
Guardian #2 Employer
Guardian #2 Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian #2 Work Phone Number
Please enter a valid phone number.
Emergency Contacts

Dragon Academy must have 3 emergency contacts (other than parents) on file. The child may be released to the guardians and to the following authorized emergency pickup person listed below.
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1 Phone Number*
Please enter a valid phone number.
Contact #1 Relationship to Child*
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2 Phone Number*
Please enter a valid phone number.
Contact #2 Relationship to Child*
Emergency Contact #3 Name*

First NameLast Name
Emergency Contact #3 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #3 Phone Number*
Please enter a valid phone number.
Contact #3 Relationship to Child*
Emergency Medical Authorization
Should your child suffer an injury or illness while in the care of Dragon Academy and the facility is unable to contact you immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. The Guardians will assume responsibility for payment of services.

Dragon Academy's Procedure will be:

1. Contact Guardians

2. Contact Emergency Contacts listed on this form if guardians cannot be reached.

3. Call emergency services team if necessary (911 first if needed)

4. Transport child via emergency Medical team to nearest hospital.
I understand this form must be updated as changes occur. This includes changes in address, home or cell numbers, emails, medical information or changes in authorized pickups and other information.

Clear
Date

MonthDayYear
Should be Empty:

Dragon Academy Enrollment Form

Child-Special Information

Parent/Guardian Information

Emergency Contacts

Emergency Medical Authorization