Covenant Community School
2019 SW Main Blvd Lake City, FL 32025
(386) 755-3636
Registration for Enrollment
Registration forms will be accepted on a first come, first served basis. Child must be 5 years old by September 1* to enroll in our K-5 program.
STUDENT INOFRMATION:
Registration for Enrollment
*
Please Select
2026-2027
Full Legal Name of Child
*
Gender:
*
Male
Female
Preferred Name (Nick Name)
SS#
*
Date of Birth
*
-
Month
-
Day
Year
Date
Requested Grade Placement
*
Please Select
Warrior Jumpstart - 3 yr olds
VPK
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Nineth
Tenth
Eleventh
Twelfth
Race/Ethnicity:
*
White
Black
Hispanic
Asian
American Indian
Multi-racial
Other
PARENT INFORMATION:
Father's complete name
*
Home Phone
Cell
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Employer
Work Address
Work Phone
E-Mail Address
*
example@example.com
Mother's complete name
*
Home Phone
Cell
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Employer
Work Address
Work Phone
E-Mail Address
*
example@example.com
PARENT SIGNATURES:
Father's Signature
*
Father's Printed Name
*
Mother's Signature
*
Mother's Printed Name
*
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Covenant Community School
2019 SW Main Blvd Lake City, FL 32025
(386) 755-3636
Medical Form
Medical Profile:Allergies/Special Health Considerations:
*
Food Restrictions:
*
Has the student been immunized according to Florida state law?
*
Yes
No
If no, please explain:
Does the student have updated Tetanus shots?
*
Yes
No
Does the student have any physical limitations that might affect his/her ability to participate in planned activities?
*
Limited
Not limited
If yes, please explain
In case of an emergency, we will call parents first. In the event parents cannot be reached, please give us a second contact name that can authorize medication and pick up your child if necessary:
Name of Additional Contact:
*
Relationship to student:
*
Cell Number
*
Home Phone
Work Phone
Address
Hospital/Clinic Preference
*
Hospital/Clinic Phone:
*
Physician's Name:
*
Physician's Phone Number:
*
Doctor Office: 2nd choice
Phone:
Insurance Company:
Name of policyholder
Policy Number:
If Medicaid, number
PE Permissions:
*
1. My child may fully participate in Pe
2. My child is limited in PE
3. My child is not allowed to participate in PE at all
4. My child is not limited but has this problem
If you picked choice 2, please explain child limitation
If you picked choice 3, please attach a doctor's statement in order for your child to be excused from PE
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If you picked choice 4, please explain problem here:
Emergency Treatment:
I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the even that neither parent/guardian can be reached in the case of an emergency.
Field Trip Permission:
I give permission for my child to go on field trips. I release Covenant Community School and individuals from liability in case of accident during activities related to Covenant Community School, as long as normal safety procedures have been taken.
Parent/Guardian's Signature
*
Date
*
-
Month
-
Day
Year
Date
Witness Signature
*
Date
*
-
Month
-
Day
Year
Date
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Covenant Community School
2019 SW Main Blvd Lake City, FL 32025
(386) 755-3636
Insurance Validation/Liability Waiver
Medical insurance coverage is encouraged for all students attending Covenant Community School. Indicate below if you have medical coverage. Please fill out your family's insurance information below and sign the waiver. If you do not have medical coverage for your child, please sign the waiver releasing Covenant Community School from all emergency medical expenses incurred due to accident, illness, or injury.
Medical coverage options
*
Yes, we have medical coverage.
No, we do not have medical coverage.
Liability Waiver
I hereby give my permission for my son/daughter to participate in the activities with the Covenant Community School program and to be under the authority of a staff member or another designated adult. I also give permission for my son/daughter to receive emergency medical attention from a physician in the event of illness or injury. I accept all financial responsibility for all expenses incurred for this medical care in the event of no medical coverage. I absolve and hold harmless the Covenant Community School Academic Program, Covenant Community Properties, or any of their Board Members or Partners from any injury or harm caused to my child or myself through whatever means or for whatever reason except for gross negligence or the school or its staff, employees, or designated representatives.
Effective from August
*
Please Select
2026
To June
*
Please Select
2027
Father's Signature
*
Mother's Signature
I, the undersigned, do hereby authorize officials of Covenant Community School to contact directly the persons named on this form and do authorize the named physicians to render such treatment as may be deemed necessary in an emergency for the health of my child(ren).
In the event parents cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment for the health of the child(ren).
I will assume full financial responsibility for the emergency care and/or transportation for said child, and will not hold the school financially responsible.
Signature of Parent/Guardian:
*
Date:
*
-
Month
-
Day
Year
Date
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Covenant Community School
2019 SW Main Blvd Lake City, FL 32025
(386) 755-3636
Pick Up Form
Last Name for car tag:
*
Enrolled Siblings Names:
*
The following person(s) may pick up my child from school. I will send in a note on the days that this will occur.
Parent Signature:
*
Date:
*
-
Month
-
Day
Year
Date
1st Contact:
*
Relation:
Driver's License Number:
State
2nd Contact:
Relation:
Driver's License Number:
State
3rd Contact:
Relation:
Driver's License Number:
State
4th Contact:
Relation:
Driver's License Number:
State
5th Contact:
Relation:
Driver's License Number:
State
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