The Academy Child Care Application

Single Line Text

Name of child:

Enrollment Type:

New Student
Returning Student

Date of Birth

Address:

Mother's name:

Telephone number:

Email:

Name & Address of Employer:

Employer Telephone Number

Father's Name:

Father's Address:

Father's Telephone Number:

Father's Email:

Name & Address of Employer (Father):

Name of 1st Authorized Person:

Relationship to Child:

Address:

Phone number:

Name of 2nd Authorized Person:

Relationship to Child

Address of 2nd Authorized Person:

Phone number:

I give permission for my child to be photographed or videotaped for The Academy of ELCC use:

Yes
No

I give permission for my child to participate in neighborhood walking trips around The Academy of ELCC, including trips to and from Eternal Life Christian Center Church:

Yes
No

List allergies your child has:

Medications/Precautions:

Child's Doctor:

Doctor's Phone Number:

Doctor's Address:

RETURNING STUDENTS

ACKNOWLEDGEMENT

Signature:

Your typed name will represent your signature.

Date: