MODABA EDUCATION CENTER
Interest Form
Share your Interest
Why are you interested in our Microschool?
How many children would you be interested in enrolling?
1
2
3
4 or more
What are the ages of your child(ren)?
What are the name(s) of your child(ren)?
Does your child(ren) have ESA funding?
Yes
No
Please tell us what you as a parent loved most about school.
Please share what you would love to see in our micrschool for your child.
Unfortunately, we can not provide transportation to school. Would your child have a reliable source of transportation to school?
Yes
No
PARENT'S NAME
PARENT'S PHONE
PARENT'S EMAIL
If interested in starting the ENROLLMENT PROCESS please complete the information below, starting with CHILDS INFORMATION. (Since we are a microschool, we have limited capacity. Therefore families will be offered an interview before acceptance to our school can be offered.)
Child's Information
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
-
Area Code
Phone Number
Age
*
Grade
*
Child's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Does this child have ESA funding?
Yes
No
Tell us something special /unique about your child(ren)?
Do you consent to photos, videos, and likeness for the purpose of promotion in news releases, photographs, video, audio, website, marketing and advertising for an indefinite period of time? If I am under 18 years of age, my parent or legal gaurdian is executing this release on my behalf and agrees to be bound by its terms.
*
yes
no
By typing your name here this will serve as your electronic signature for consent.
*
ALLERGIES: PLEASE SHARE ANY ALLERGIES AND/OR FOOD RESTRICTIONS
Please list any additional children you'd like to consider for enrollment (Child 2)
Name
Grade
Age
Gender
Does this child have ESA funding?
Yes
No
Please list any additional children you'd like to consider for enrollment (Child 3)
Name
Grade
Age
Gender
Does this child have ESA funding?
Yes
No
Please list any additional children you'd like to consider for enrollment (Child 4)
Name
Grade
Age
Gender
Does this child have ESA funding?
Yes
No
Please list any additional children you'd like to consider for enrollment (Child 5)
Name
Grade
Age
Gender
Does this child have ESA funding?
Yes
No
Attendance Information (FOR KINDER ONLY)
Expected Start Date
-
Month
-
Day
Year
Date
From
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
To
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Days of Attendance
Monday
Tuesday
Wednesday
Thursday
Additional Information regarding Attendance
Patents/Guardian & Emergency Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Relationship
*
Mother, Father, etc
Mobile Phone Number
*
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Address
*
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
First Name
Last Name
Email
example@example.com
Relationship
Mother, Father, etc.
Mobile Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Address
Same with the child
Different Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 1
*
First Name
Last Name
Relationship
Home Phone Number
*
-
Area Code
Phone Number
Mobile Phone Number
-
Area Code
Phone Number
Emergency Contact 2
*
First Name
Last Name
Relationship
Home Phone Number
-
Area Code
Phone Number
Mobile Phone Number
*
-
Area Code
Phone Number
In the event of an emergency what is your hospital preference?
*
Insurance Provider
Marital status of parents, medical information, people who the child cannot be released, etc
*
Parent involvement (Parents are required to volunteer 5 hours per month, please share your ideal availability)
Please share your availability (M-F)
*
Additional Information
Is there is anything else we should know about your child or your family that was not shared above i.e. Religious preference, sensory needs, etc.
*
Submit
Should be Empty: