STUDENT INFORMATION
Student Name
Grade Entering
Date of Birth
Gender
Enrollment Status
New Student
Returning Student
Scholarship Application
Indiana Choice Scholarship
SGO Scholarship
Unsure If Student Qualifies for Funding
Not Applying
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FAMILY INFORMATION
Parent / Guardian 1
Name
Relationship
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Employer
Parent / Guardian 2
Name
Relationship
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email
example@example.com
Employer
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HOME INFORMATION
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Lives With
Both Parents
Mother
Father
Guardian
Other
Custody Notes
PREVIOUS SCHOOL IF ANY
Previous School
City
Grade
Permission to Request School Records
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MEDICAL INFORMATION
Primary Physician
Phone
Format: (000) 000-0000.
Dentist
Emergency Phone
Format: (000) 000-0000.
Allergies
Medical Conditions
Current Medications
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EMERGENCY CONTACTS
Name
Relationship
Phone
Format: (000) 000-0000.
Name
Relationship
Phone
Format: (000) 000-0000.
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AUTHORIZED PICKUP IF OTHER THAN PARENTS
Name
Relationship
Phone
Format: (000) 000-0000.
Name
Relationship
Phone
Format: (000) 000-0000.
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BEFORE & AFTER SCHOOL CARE
Before School Care
After School Care
Both
None
Days Needed
Monday
Tuesday
Wednesday
Thursday
Friday
Expected Pickup Time
Hour Minutes
AM
PM
AM/PM Option
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PARENT AUTHORIZATIONS
Release Educational Records
Request Previous School Records
Emergency Medical Authorization
Minor First Aid Authorization
Permission to Apply Antibiotic Ointment
Permission for Administration of Ibuprofen (per school policy)
Indiana CHIRP Authorization
Photo & Media Release
School Website & Social Media Permission
Field Trip Participation Permission
Technology & Internet Acceptable Use Agreement
Parent/Student Handbook Received
Tuition & Financial Agreement Received
PARENT CERTIFICATION
I certify that all information provided in this registration packet is true and complete to
the best of my knowledge.
Parent/Guardian Signature
Printed Name
Date
Submit
OFFICE USE ONLY
OFFICE USE ONLY
Rows
Status
Registration Fee Paid
Birth Certificate Received
Immunization Records
Received
Records Requested
Records Received
Indiana Choice Verified
Student Accepted
Enrollment Approved
Processed By
Date
Should be Empty: