Empowered Learners Private School Registration 2025-2026

Empowered Learners Private School New Student Registration

2025-2026
Student Information
Full Name*
Name to be called/written at school
Date of Birth *

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Previous Preschool/Childcare*
Child lives with*

Both ParentsDadMomOther
If Other, please list name and relationship.
Name(s) & Age(s) of siblings (write N/A if none)*
Medical or Developmental Issues (allergies, hearing, eyesight, behavior, attention deficit, etc.) (write N/A if none)*
Fears, Worries or Dislikes (write N/A if none)*
Mother's Information
Name*
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer & Occupation
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Father's Information
Name*
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer & Occupation
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Authorizations & Releases
Emergency Contact Information: * In the absence of parents, child can be released to: *
List up to 2 contacts other than parents (Name, Relationship to Child and Phone Number)
Child Pick up Authorization: * other than Parents & Emergency Contacts*
List up to 3 contacts other than parents (Name, Relationship to Child and Phone Number)
Is there a court order preventing anyone from picking up your child? (If a court order exists, Empowered Learners will need to be provided with a copy to keep on file.)*

YesNo

Medical Release
Authorization to seek medical and dental treatment: Should an emergency arise, I authorize Empowered Learners Private School to seek medical and/or dental care for my child at the nearest medical facility. I understand that I am responsible for any financial expenses that may incur.
Child's Physician *
Name
Child's Physician Number*
Please enter a valid phone number.
Child's Dentist*
Name
Child Dentist Number*
Please enter a valid phone number.
Name*

First NameLast Name
Insurance Information

Insurance GroupGroup #
Medical/Dental permission care for my child.*

I do give my permission upon emergency for Empowered Learners to seek Medical/Dental care for my child, including transport.I do NOT give my permission upon emergency for Empowered Learners to seek Medical/Dental care for my child, including transport.
Signature*

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Signature Date*

MonthDayYear

Liability Waiver
This agreement releases The Sending House and Empowered Learners Private School from all liability relating to injuries that may occur during activity on location. By signing this agreement, I agree to hold The Sending House and Empowered Learners Private School entirely free from any liability, including financial responsibility for injuries incurred. I also acknowledge the risks involved in attending Empowered Learners Private School and The Sending House. These include but are not limited to injuries on the playground equipment, tripping over something in the building, or falling and hurting themselves.
By signing below, I forfeit all right to bring a suit against The Sending House or Empowered Learners Private School for any reason. In return I will receive participation in the Private School at The Sending House. I will also make sure my child makes every effort to obey safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.
I * fully understand and agree to the terms above. Signature*
Date*

Financial Agreement
I, * agree to pay 10 tuition payments for the months of August 2025-May 2026. I acknowledge that Empowered Learners has the right to take legal action if the agreement is not fulfilled.
Signature*
Date*
Student/Parent Handbook
I, * have read the student/parent handbook in full and understand the contents of it completely. I acknowledge that this handbook can be amended accordingly by the Empowered Learners Private School staff.
Signature*
Date*
Media Release
Media Release*

I do give my permission for Empowered Learners Private School to post my child's picture on Facebook, Group Me or empoweredlearnerstx.comI do NOT give my permission for Empowered Learners Private School to post my child's picture on Facebook, Group Me or empoweredlearnerstx.com
Signature*

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Signature Date*

MonthDayYear
Date
PTO
Empowered Learners is seeking a PTO to help support our teachers and students. Some of the responsibilities of a PTO member would be:
1. Planning the Christmas and Easter parties
2. Planning a spring Bingo night for the families of EL
3. Doing a once-a-quarter (4 times a year) teacher appreciation treat
4. Helping teachers cut things out
5. Checking in with teachers to see what is needed for students
  *

Signature*
Date*
Should be Empty:

Empowered Learners Private School New Student Registration

Student Information

Mother's Information

Father's Information

Authorizations & Releases

Medical Release

Authorization to seek medical and dental treatment: Should an emergency arise, I authorize Empowered Learners Private School to seek medical and/or dental care for my child at the nearest medical facility. I understand that I am responsible for any financial expenses that may incur.

Liability Waiver

Financial Agreement

Student/Parent Handbook

Media Release

PTO