Magnolia Learning Academy

Magnolia Learning Academy

Registration Form
Child's Name*

First NameLast Name
Child's Birth Date:*

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Child's Current School Name*
School Name
Child's Current Grade*
Grade
Mother's/Guardian's Name*

First NameLast Name
Mother's/Guardian's Cell Phone Number:*
Mother's/Guardian's E-mail*
example@example.com
Father's/Guardian's Name*

First NameLast Name
Father's/Guardian's Cell Phone Number:*
Father's/Guardian's E-mail*
example@example.com
Is a parent in the military?*
Military Parent
Are there any security/custody issues with this child?*
If you answered "YES" to the question above, please help us to know the security/custody issues for the safety of your child.
Security/Custody Issues
Does the child have any special needs (ADD, Asperger’s, Dyslexia, etc.)*
If you answered "YES" to the question above, please list the special needs of the child. (ADD, Asperger’s, Dyslexia, etc.)
Special Needs
Does your child currently receive any outside/in school services?

ABA (Applied Behavior Analysis)Physical TherapyOccupational TherapySpeechMental Health TherapyTalk Therapy
If you selected any of the above services, please list where your child is currently receiving those services.
What days of the week are you interested in your child attending?

Full Time: Monday-FridayHybrid: Tuesday-Thursday
Does your child have any allergies? (peanuts, chocolate, etc.)*
If you answered "YES" to the question above, please list your child's allergies.
Allergies
Please describe your child's strengths and weaknesses:
My child appears to be more successful when.... (please include any items you think would help your child be most successful)
Emergency Contact #1*

First NameLast Name
Phone Number*
Emergency Contact #2*

First NameLast Name
Phone Number*
In addition to those listed above (Guardian, Parents, & Emergency Contacts), please list the individuals who are also allowed to pick up your child from school.*
Allowed to pick up child.
Do you agree to provide your own transportation for your child to and from school?

YesNo
Please list any individual who is NOT allowed to pick up your child from school.
NOT Allowed to pick up child.
Referred by? Where did you hear about us?
Parent's/Guardian's Name*

First NameLast Name
Signature

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