Enrollment Form
Please complete every question on this application. Incomplete applications will be rejected
Name of Student
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Address
Street Address
Street Address Line 2
Twon
Parish
Country
List all the schools previously attended.
Parent 1 Information
First Name
Last Name
Current Status
Married
Divorced
Single
Common Law
Address
Street Address
Street Address Line 2
Town
Parish
Country
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Are you employed?
Please Select
Yes
No
If your answer above was yes, please provide the name of your job, Address and telephone number.
Parent 2 Information
First Name
Last Name
Current Status
Married
Divorced
Single
Common Law
Address
Street Address
Street Address Line 2
Town
Parish
Country
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you employed?
Please Select
Yes
No
If your answer above was yes, please provide the name of your job, Address and telephone number.
Emergency Contact 1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 3
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Great Start Academy is committed to wholistic development of every child. The information you provide will help us to know the child better. Please list all the siblings in the home ( if any). Be sure to include name and ages.
With whom does the child live?
Parent 1
Parent 2
Both parents
Other __________________
Does your child have any special needs/requirements ( Learning, Physical, Cognitive) Including but not limited to ( Autism, Attention Deficit Disorder, Dyslexia, Behavioral Challenges, Hearing or Visual impairment). This information is needed so we can make preparation for your child.
yes
no
If you responded yes to the above, please explain.
Does your child have any allergies, if yes please let us know below.
What are your child's fears? e.g height, insects, dogs
Why did you choose Great Start Academy? In what way would you like to see this institution impact your child?
Additional information ( Optional)
Signature
Date
-
Month
-
Day
Year
Date
Continue
Continue
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