Enrollment Application
Little Rock Preparatory Academy
13250 NW 28th Avenue, Opa-Locka Florida 33054
Student Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Male/Female
*
Please Select
Male
Female
Grade
*
Please Select
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Student Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Social Security #
*
Social Security #
Parent Name
*
First Name
Last Name
Parent Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
Parent Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Child Care Contact Information and Consent Form
Childs Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Male/Female
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian
*
First Name
Last Name
Work
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cellular
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact (To whom child may be released if guardian is unavailable)
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Child's Preferred Sources of Medical Care
Physician's Name
Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician's Phone Number
Physician's Phone
Format: (000) 000-0000.
Dentist's Name
Dentist's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist's Phone Number
Format: (000) 000-0000.
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Child's Health Insurance
Insurance Plan
Plan Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance ID#
ID#
Subscriber's Name
On insurance Card
Special Conditions, Disabilities, Allergies, or Medical Emergency Information
As parent/guardian, I consent to have my child receive first aid by facility and, if necessary, be transported to receive emergency care. I will be responsible for all charges not covered by insurance. I consent for the emergency contact person listed above to ACT ON MY BEHALF until I am available. I agree to review and update this information •whenever a change occurs and at least every 6 months
*
Should be Empty: