Student’s Information:

     

    Gender

     

    Is English your student's primary language?

     

    If No Please Specify

     

    Preferred Name

     

    Birth Date(DD/MM/YYYY)

     

    Student’s Current Age

     

    Student's Current Grade

     

    What is the name of your school? What city is it in?

     

    Are you interested in carpooling with another family?

     

    Class Session/Schedule:

       

      Group Age

       

      If Other Please indicate

       

      Session

       

      Indicate Day/s & Dates of Enrollment:

       

      Program Schedule (Hours)

       

      Address

       

      Address2

       

      City

       

      State

       

      Zip Code

       

      Business Number

       

      Business Number

       

      If parents are separated, who is the custodial parent

       

      Medical Information:

         

        Student’s Doctor

         

        Doctor’s Phone Number

         

        Student’s Dentist

         

        Dentist's Phone Number

         

        Medical Conditions/ Concerns

         

        Medications Taken / Allergies

         

        Health Insurance

         

        Policy Number

         

        Hospital Preference

         

        Note: In event of apparent serious illness, accident or disaster, when I cannot be reach I wish one of the following person(s) to be notified by telephone. They are authorized to act in my absence, and will be informed that their names have been used.

           

          It must be someone who is available during the day and can be easily reached. Do not list parents in the spaces below. **At least two minimum**

             

            Name

             

            Relationship

             

            Address

             

            Home Number

             

            Mobile Phone

             

            City

             

            State

             

            Zip Code

             

            Name

             

            Relationship

             

            Address

             

            Home Number

             

            Mobile Phone

             

            City

             

            State

             

            Zip Code

             

            Release Information:

               

              Throughout the session, the children participate in several different special events at Welcome Amigos. We like to capture these special moments by taking pictures and/or videotaping. We use these materials to share them with families.

                 

                In addition, we would like to use these pictures/videos on the web site, and in some of our publications. Only Welcome Amigos will use these pictures

                   

                  Please indicate if you give permission.

                   

                  Student’s Name

                   

                  Parent's Initials

                   

                  Date(DD/MM/YYYY)

                   

                  Pick-up Authorization:

                     

                    Are there any additional persons authorized to pick up your kid(s) ?

                     

                    If yes, please provide the information of the person(s) other than yourself authorized to transport your child to/from school, including those in your carpool:

                       

                      Full Name

                       

                      Relationship to Student

                       

                      Full Name

                       

                      Relationship to Student

                       

                      Parent's/Legal Guardian’s Initials

                       

                      Date (DD/MM/YYYY)

                       

                      Additional Comments

                       

                      *We will send you an e-mail within 12 hours confirming your total tuition.

                         

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