Brightleaf Academy Application Form

Brightleaf Academy Application Form

Pre-K-5th grade
Date

MonthDayYear
Date
Incoming Grade Level*
Name of Student

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Gender

MaleFemale
Ethnicity
Is the applicant child bilingual/multi-lingual?

YesNo
Please Specify the Languages Spoken
Primary Language Spoken at Home
Please select the kind of registration you are applying for:

New StudentTransferree (including child care center)Continuing
School Transferring From
Email for Teacher/Facility Recommendation
example@example.com
School Phone Number
Please enter a valid phone number.

Family Information
Name of Father

First NameLast Name
Occupation
Work Phone Number
Please enter a valid phone number.
Address (if not same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Mother

First NameLast Name
Occupation
Work Phone Number
Please enter a valid phone number.
Address (if not same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Siblings
Student Lives With

Both ParentsMotherFatherAppointed Legal Guardian (neither parents)
Name of Legal Guardian

First NameLast Name
Occupation
Work Phone Number
Please enter a valid phone number.
Address (if not same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com

Medical and Health Information
Will your child be taking any medications at home or at school?

YesNo
Please provide details
Does your Child have any allergies to any of the following: Insect Bites, Food, Seasonal Allergies, Latex, Medicine, etc.

YesNo
Please provide details

Acknowledgement, Authorization, and Consent
By signing this form, I hereby authorize the school to use the information herein provided for the processing of my child's application. I understand that the information shared herein shall be for the purpose of the admission of my child to Brightleaf Academy.

I authorize and provide consent to the school in releasing my child's medical and health information with the school's health services.

In the event that my child becomes ill, sustains an injury, or in any case, needs immediate medical care during under the care and supervision of the school, I hereby authorize the school to administer first aid for my child's relief.

In the event that my child needs immediate attention and it is not practical to wait for receiving instructions from the parents or appointed legal guardian or the child, I, as a parent/legal guardian, hereby authorize the school, its staff, to act as agents in delivering my child to a hospital and performing decisions necessary as recommended by an attending physician for the care of my child such as conducting X-ray, anesthetic, and other medical treatments such as surgery.

I further declare that the information I have provided in this form is true and correct to the best of my knowledge.

***Once payment is received, the application will be reviewed and a recommendation notice sent to the previous teacher/school. We will schedule a time for you and your child to come in for an "entrance" meet and greet in the coming weeks.
Signature of Parent/Guardian

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Name

First NameLast Name
Date

MonthDayYear
Date

My Products

Brightleaf Academy Application Fee Product Image

Brightleaf Academy Application FeeNon-Refundable Application Fee- Not included in Tuition Fees.

$100.00 Quantity

Brightleaf Academy Application Fee (Sibling) Product Image

Brightleaf Academy Application Fee (Sibling)$50/per sibling-Non-Refundable Application Fee- Not included in Tuition Fees.

$50.00 Quantity

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$0.00

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Brightleaf Academy Application Form

Family Information

Medical and Health Information

Acknowledgement, Authorization, and Consent