Karapetyan Elementary School

Child's Name*

First NameLast Name

Child's Birth Date:*

MonthDayYear

Address:

Street Address

Street Address Line 2

CityState

Zip Code

Child's Age*

Grade

Grade or Program*

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

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 have any allergies? (peanuts, chocolate, etc.)*

If you answered "YES" to the question above, please list your child's allergies.

Allergies

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.

Please list any individual who is NOT allowed to pick up your child from school.

NOT Allowed to pick up child.

Parent/Gaurdian Name*

First NameLast Name

Signature*

By signing this form, I acknowledge and agree that Heritage Private Elementary School is not liable for any illnesses, including but not limited to communicable diseases, that may occur as a result of my child’s enrollment. I also understand that the school is not responsible for any lost, stolen, or damaged personal property, nor for any injuries sustained by my child on school grounds or during school-related activities. I further agree that all tuition and fees paid are strictly non-refundable under any circumstances. Additionally, I acknowledge that I am required to provide a minimum of 30 days’ written notice prior to withdrawing my child from the program, and failure to do so may result in continued tuition obligations.