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: *