Legacy Academy Registration Form

Legacy Academy

2023-2024 REGISTRATION FORM
Student's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN INFORMATION
Full Name

First NameLast Name
Cell Phone #

Area CodePhone Number
Alternate Phone #

Area CodePhone Number
Email
example@example.com
Full Name

First NameLast Name
Cell Phone #

Area CodePhone Number
Alternate Phone #

Area CodePhone Number
Email
example@example.com
EMERGENCY CONTACT INFORMATION: Other than Parent/Guardian
Full Name

First NameLast Name
Phone #

Area CodePhone Number
Relationship to Student
Full Name

First NameLast Name
Phone #

Area CodePhone Number
Relationship to Student
Does your child child have any problems, injuries or allergies that might affect her/him from fully participating in the activities at The Legacy Academy? Please describe and include additional notes to the staff here:
Registration assumes full participation in the ENTIRE year of classes. A deposit of $250 via cash, check (made out to The South Gate), or the Church Center app (choose "Legacy Academy" on the dropdown menu) is required to secure your child's spot.
Should be Empty: