Form

Adventure Kingdom Academy Child Enrollment Application
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Sex*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
- Father's Name*
- Father's Email Address*
  example@example.com
- Father's Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Father's Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Father's Employment/ Work Phone*
- Mother's Name*
  
  First NameLast Name
- Mother's Email Address*
  example@example.com
- Mother's Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Mother's Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Mother's Employment/Work Phone*
- Living Arrangement*
- Legal Guardian*
- Authorized Pick Ups - Include Full Name, Phone Number, Relationship (At Least 2)*
- Emergency Contacts - Include Full Name, Phone Number, Relationship (At Least 2)*
- Provider's Full Name*
  
  First NameLast Name
- Provider's Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Provider's Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Allergies/Health Conditions*
- Medications*
- Emergency Medical Authorization
  
  “In the event of a medical emergency, I authorize Adventure Kingdom Academy to seek treatment for my child _________________."
- Signature*
  
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- Date*
  
  MonthDayYear
  Date
- Parental Agreement
  
  “I acknowledge I’ve received and agree to the policies and procedures of Adventure Kingdom Academy…”
- Signature*
  
  Powered by Jotform SignClear
- Date*
  
  MonthDayYear
  Date
- Should be Empty:

Adventure Kingdom Academy Child Enrollment Application