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4K Prep Academy LLC – Student Registration Form GENDER

STUDENT’S LEGAL NAME

_____________________________________________________________________________________________ LAST FIRST MIDDLE NAME

                          OFFICE  USE  ONLY   

Male Female

STUDENT ID # ________ FAMILY ID# ________ 

HOME TELEPHONE

STUDENT’S ADDRESS

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________________________________________________________________________________________ ADDRESS & P.O. BOX CITY STATE ZIP

)

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Email Address: __________________________________________________________________________

____________ ____________ ___________ MONTH DAY YEAR STUDENT’S BIRTH PLACE __________________________ _________ CITY STATE

STUDENT’S BIRTH DATE

All parents/guardians are permitted to visit during center hours and are allowed to pick up the child unless access is prohibited or restricted. Please complete the Custodial Placement form and attach court order, if any. CHILD LIVES WITH BOTH PARENTS LIVES WITH MOTHER; FATHER WANTS COPIES OF REPORT CARDS, ETC. ETHNICITY BOTH PARENTS – DIFFERENT LAST NAMES LIVES WITH FATHER; MOTHER WANTS COPIES OF REPORT CARDS, ETC. Choose one or more. You must select at least one) FATHER AND STEP-MOTHER MOTHER AND STEP-FATHER MOTHER AND FATHER-JOINT CUSTODY SINGLE PARENT FOSTER PARENTS

HOME LANGUAGE:

English

Hmong

MOTHER, FATHER CANNOT SEE CHILD (DOCUMENTATION REQUIRED) FATHER, MOTHER CANNOT SEE CHILD (DOCUMENTATION REQUIRED) OTHER RELATIVE LEGAL GUARDIAN OTHER __________________________________________________________

Russian

Spanish

Somali

Other:__________________________

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Is this child Hispanic or Latino?

(Choose only one)

No, not Hispanic or Latino Yes, Hispanic or Latino

FATHER’S NAME __________________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL _______________________________________________________________ EMPLOYER

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________________________________ WORK PHONE

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______________________________________________________________________________________________ ADDRESS AND TELEPHONE (IF DIFFERENT FROM STUDENT)

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_________________________________ CELL PHONE

_____________________________________________________ EMAIL ADDRESS

MOTHER’S NAME __________________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL _______________________________________________________________ EMPLOYER

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_______________________________ WORK PHONE

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__________________________________ CELL PHONE

STEP-PARENT, LEGAL GUARDIAN, FOSTER PARENT, OTHER __________________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL _______________________________________________________________ EMPLOYER

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_______________________________ WORK PHONE

_______________________________________________________________ EMPLOYER

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_______________________________ WORK PHONE

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_____________________________________________________ EMAIL ADDRESS

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______________________________________________________________________________________________ ADDRESS AND TELEPHONE (IF DIFFERENT FROM STUDENT)

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__________________________________ CELL PHONE

STEP-PARENT, LEGAL GUARDIAN, FOSTER PARENT, OTHER __________________________________________________________________________________________________ LAST NAME FIRST NAME MIDDLE INITIAL

)

______________________________________________________________________________________________ ADDRESS AND TELEPHONE (IF DIFFERENT FROM STUDENT)

_____________________________________________________ EMAIL ADDRESS

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______________________________________________________________________________________________ ADDRESS AND TELEPHONE (IF DIFFERENT FROM STUDENT)

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__________________________________ CELL PHONE

_____________________________________________________ EMAIL ADDRESS


4 Prep Academy LLC – Student Registration Form OTHER CHILDREN IN FAMILY: Please list last name, first name, and middle name of each child. 1.

BIRTHDATE

GENDER

SCHOOL

2. 3. 4. PERSONS OTHER THAN PARENTS/GUARDIANS WHO ARE AUTHORIZED TO PICK UP CHILD-Provide information requested for each person. If no one, write “None” EMERGENCY CONTACT- Provide information for the person to contact when parents/guardians cannot be reached. Relationship to Child Name Home Address Home Phone Cell/other phone Work Phone

PHYSICIAN OR MEDICAL FACILITY Name of Clinic/Facility

Name of Physician

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Address

Telephone Number (

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AUTHORIZATION † Yes † No I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately. † Yes † No † Transported † Walking - I give permission for my child to participate in field trips and other activities during operating hours. My child will be 4 years on or before Sept 1: † Yes † No Comments or concerns you may have regarding your child attending the four-year-old Kindergarten program (medical, speech, behavior, etc.) _____________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________ Please specify your preference of AM or PM session.  AM PM Please complete the registration form at your earliest convenience and submit it to secure your child's enrollment to 2200 Dickinson Road Unit 15, Suite D De Pere, WI 54115 . We will do our best to accommodate all requests. A confirmation will be sent to you upon approval, along with a full enrollment package. Please bring the following documents with your child’s registration form: • Birth Certificate • Immunization Record • Proof of residency (utility or phone bill with home address) ___________________________________________________________________________________

Print Name of Parent/Guardian

__________________________________________________ Signature of Parent/Guardian

______________________________ Date


4K Prep Academy 2011 Registration