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Name of Student*

First NameLast Name

Student's Date of Birth*

Date

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School (if applicable)

Grade Level*

Language Spoken at Home

Special Needs or Accommodations*

Any extracurricular activities or interests

Additional Comments or Notes

Parent/Guardian Name*

First NameLast Name

Relationship to Student*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Relationship to Student*

ParentGuardianRelativeOther

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Relationship to Student*

ParentGuardianRelativeOther

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Please list any relevant medical conditions, allergies, or medications.

Consents and Authorizations:

Please tick the boxes below*

I agree to grant my consent to manage emergencies if no contact is establishedI will keep my sick child home and notify the programI will supply any necessary medicationI consent to pay any medical charges or expenses that could be incurred in case of emergency.

Photography and Videography Consent

I consent to the photography and/or videography of my child. I understand that any photos or videos will be used solely for marketing purposes. If you do not respond to this consent request, your consent to photography and/or videography of your child will be assumed.*

Opt In: I consent to photography and/or videography of my child for marketing purposes.Opt Out: I do NOT consent to photography and/or videography of my child.

Consent for Receiving Marketing Communications

Please indicate your preference for receiving marketing materials from Flourishing Minds Academy.*

Email: I consent to receive marketing emails.SMS/Text Message: I consent to receive marketing SMS/text messages.Phone Call: I consent to receive marketing phone calls.No Contact: I do NOT wish to receive any marketing communications.

You may update or withdraw your preferences at any time by contacting us on our email flourishing.minds.academy@gmail.com with "Unsubscribe" in the subject. Your privacy is important, and your contact details will be handled confidentially in accordance with our privacy policy.

By signing below, I hereby authorize the Flourishing Minds Academy to use the information provided for educational and administrative purposes. I certify that the information provided is accurate and complete to the best of my knowledge.

Parent/Guardian Signature (if student is a minor)*

Date Signed*

Date

Student Information Sheet

Student Information

Parent/Guardian Information:

Emergency Details 1

Emergency Details 2

Additional Medical Information:

Payment Methods