MLA Student Enrollment Form

More Information Regarding Your Child
Please list any special needs/concerns related to the care of your child, such as allergies, existing illnesses, previous illnesses, and injuries during the past twelve months, any medications taken for long-term use, and any other information, which the staff should be aware of:*
Emergency Care Plan (if applicable):
I hearby grant the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.
Doctor Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Doctor Phone Number*

Area CodePhone Number
Hospital Preference*
Dentist Name
Phone Number

Area CodePhone Number
Mitchell Learning Academy occasionally uses photography and/or video/voice recording for advertising purposes and secure communication on our parent app. Your confirmation below indicates your consent as parent or guardian to allow your child to be photographed and/or recorded while at Mitchell Learning Academy, on fields trips, or during activities. These image(s) will be used to promote child care services ONLY, either in print, directly to you through our parent app or on our website/social media outlets. This form will remain in effect during the child’s enrollment at Mitchell Learning Academy or until you as the parent/guardian wishes to terminate the photography authorization to use the photo(s). No payment will be issued for the child’s participation in this release.*
As the parent/guardian of this child, I hereby give my permission to Mitchell Learning Academy to seek emergency medical care and treatment should an emergency arise. It is understood that a conscientious effort will be made to locate me before emergency action will be taken. If this is not possible, I understand the expenses of emergency medical treatment or care will be at the cost of the parent.*
**Electronic Communication: You have a choice in participating in SMS Text Messaging and emails from Mitchell Learning Academy regarding school closings or upcoming events. This applies to all numbers listed on this registration form.*
**Text message charges may apply, depending on your service plan. Please check with your wireless provider.
My child may consume store-bought treats that may be purchased for special events by MLA staff or other center parents.

YesNo

Entry Disclosures
The Student has been expelled from school.*
If Yes, name of school, city and state
The student has been referred to mental/behavioral health services in the past.*

VPK AP3 Scores

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Teacher Recommendation Letter

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Application Submission

I confirm that I am authorized to apply for K-2 admission for this student with Mitchell Learning Academy. I further confirm that the information submitted in this enrollment application is true and accurate. I also understand that the non-refundable fee of $100 must be paid to officially begin the application review process and does not guarantee admission. Please call or email us to ensure an invoice is sent for payment. The application fee is non-refundable but can be covered by the Step Up for Students Scholarship. Please visit www.StepUpforStudents.org to apply today!

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K-2 Application Fee$100.00

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Total $0.00

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Private School K-2 Student Registration Form

Parent/Guardian Contact Information

Emergency Contact/Authorized Pick Up List

More Information Regarding Your Child

Marketing/Communication

Entry Disclosures

Application Submission

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