Esprit de Corps Center for Learning

Mother/Legal Guardian's Name: (circle one)

Father/Legal Guardian's Name: (circle one)

Language(s) spoken in the home:

Brothers: Number older Number older Sisters:

Number in school Number in school

Names of brothers and sisters attending EDC:

Does student have any physical or emotional disabilities? (check one): If yes, please explain, and provide the office with a doctor's verification.

YesNoIf yes, list name(s) of Is child on prescription medication? (check one): medication, and complete an EDC Medical Authorization form if your child must take medication while at school:

Does your child have any food allergies? (check one): YesNoIf yes, list name(s) of food allergies; parent must provide an authorized allergy assessment/statement regarding your child's allergy any food:

Person(s) to contact in case of emergency who is authorized to remove child from school when parent or legal guardian cannot be reached:

I understand that should my marital status or any other information change, it is my responsibility to provide updated information to Esprit De Corps Center for Learning.

Esprit de Corps Center for Learning does not discriminate on the basis of race, color, national or ethnic origin in the administration of its hiring policies, student admissions, or other school administered programs.