2021-2022 SJCA SCRIP Enrollment & Waiver Form

2025-2026

Certificate Attesting to Age of Child

*Required for all new incoming 3K, 4K and Kindergarten students*
Student Name*

First NameLast Name
I, name of parent/guardian* being the parent/guardian oflegal name of child* being first duly sworn on oath and being informed as to the requirements of the Board of Education that:
Grade applying for:*

3K4KKindergarten
- to be eligible for enrollment in KINDERGARTEN a child must be five (5) years of age on or before September 1st
- to be eligible for enrollment in 4K a child must be four (4) years of age on or before September 1st of such year
- to be eligible for enrollment 3K a child must be three (3) years of age on or before September 1st of such year
herewith submit the following information for determination as to such child's eligibility and certify it to be true and correct.
Students Age on or before September 1st, 2025*
Birth Date*

MonthDayYear
Date
Birth City*
Birth County*
Birth State*
Birth Country*
Email
example@example.com
Birth Certificate (scan, screenshot or legible picture taken with camera)*

Cancelof
Parent/Guardian Signature*

Clear
Should be Empty: