New Student Enrollment

Student 1

*Last Name*First NameMiddle Name*Preferred Name*Expected Start Date*Date of Birth (mm/dd/yyyy)Church AffiliationSuffixTitle*City, State, Country of Birth*Gender*RaceStudent E-Mail*Grade Level Applying ForBlood Type*School Currently AttendingAll starred items must be filled in. If an item is not applicable please type NA. Thank you!

*Your childs gifts or talents*Tell your childs personality*List any behavior problems*Home Discipline methods usedOther Family members in the home: Name, Age & Relationship*Other family living in home

Please state any health or medical issues that involve physical problems, pertinent developmental information, special accommodations needed:*Any Serious illness*List health or mental issues*Any Seriou hospitalization*List regular medications given*List all allergiesWhen listing allergies, please include: intolerance to food, medications, etc., and action to take in an emergency.

Student 2

Student 3

Student 4

Student 5

Primary Family Information

*Address Line 1All starred items must be filled in. If an item is not applicable please type NA. Thank you!Address Line 2*City*State*ZIP Code*Home PhoneHome ListedMobile PhoneMobile Listed

Parent 1 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch Affiliation*Relationship to Child*GenderRace*E-Mail*Mobile PhoneMobile Listed*Company Name*Business Phone*ExtensionJob TitleIs Emergency ContactAll starred items must be filled in. If an item is not applicable please type NA. Thank you!Business E-MailIs Allowed to Pickup*Company Address

By typing my name in the "Custodial Parent Name" box I agree to the below statement and I understand that this is an electronic document signed online and a legally binding esignature.*Custodial Parent NameThe parent(s) guardian authorizes VICTORY CHRISTIAN PRESCHOOL & ACADEMY to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that his agreement covers only those situations which are true emergencies and only when he/she cannot be reached. Otherwise he/she expects to be notified immediately. I understand that this form will be taken with my child to the nearest hospital in case of an emergency.

Parent 2 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch Affiliation*Relationship to Child*GenderRace*E-Mail*Mobile PhoneMobile Listed*Company Name*Business Phone*ExtensionJob TitleIs Emergency ContactAll starred items must be filled in. If an item is not applicable please type NA. Thank you!Business E-MailIs Allowed to Pickup*Company Address

By typing my name in the "Custodial Parent Name" box I agree to the below statement and I understand that this is an electronic document signed online and a legally binding esignature.*Custodial Parent NameThe parent(s) guardian authorizes VICTORY CHRISTIAN PRESCHOOL & ACADEMY to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that his agreement covers only those situations which are true emergencies and only when he/she cannot be reached. Otherwise he/she expects to be notified immediately. I understand that this form will be taken with my child to the nearest hospital in case of an emergency.

Secondary Family Information

*Address Line 1All starred items must be filled in. If an item is not applicable please type NA. Thank you!Address Line 2*City*State*ZIP Code*Home PhoneHome ListedMobile PhoneMobile Listed

Parent 3 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch Affiliation*Relationship to Child*GenderRace*E-Mail*Mobile PhoneMobile Listed*Company Name*Business Phone*ExtensionJob TitleIs Emergency ContactAll starred items must be filled in. If an item is not applicable please type NA. Thank you!Business E-MailIs Allowed to Pickup*Company Address

By typing my name in the "Custodial Parent Name" box I agree to the below statement and I understand that this is an electronic document signed online and a legally binding esignature.*Custodial Parent NameThe parent(s) guardian authorizes VICTORY CHRISTIAN PRESCHOOL & ACADEMY to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that his agreement covers only those situations which are true emergencies and only when he/she cannot be reached. Otherwise he/she expects to be notified immediately. I understand that this form will be taken with my child to the nearest hospital in case of an emergency.

Parent 4 Information

*Last Name*First NameMiddle NamePreferred NameDate of BirthMarital StatusSuffixTitleChurch Affiliation*Relationship to Child*GenderRace*E-Mail*Mobile PhoneMobile Listed*Company Name*Business Phone*ExtensionJob TitleIs Emergency ContactAll starred items must be filled in. If an item is not applicable please type NA. Thank you!Business E-MailIs Allowed to Pickup*Company Address

By typing my name in the "Custodial Parent Name" box I agree to the below statement and I understand that this is an electronic document signed online and a legally binding esignature.*Custodial Parent NameThe parent(s) guardian authorizes VICTORY CHRISTIAN PRESCHOOL & ACADEMY to obtain immediate medical care and consents to the hospitalization of, the performance of necessary diagnostic test upon, the use of surgery on, and/or the administration of drugs to, his/her child or ward if an emergency occurs when he/she cannot be located immediately. It is also understood that his agreement covers only those situations which are true emergencies and only when he/she cannot be reached. Otherwise he/she expects to be notified immediately. I understand that this form will be taken with my child to the nearest hospital in case of an emergency.

Contact Information (Other than parents)

Contact 1

*Last Name (2 people other than the parent/legal guardian)*First Name*RelationIs Emergency ContactAll starred items must be filled in. If an item is not applicable please type NA. Thank you!*PhoneIs Allowed to Pickup*PhonePickup License*Mobile PhonePickup Tag*Pickup NotesIn the Pick up Notes, please type the Home Address for those considered Emergency Contacts who ARE NOT THE CUSTODIAL PARENT. You need atleast 2 people to be emergency contacts. However, you can have an unlimited number of regular contacts to be able to pick up your child.

Contact 2

Contact 3

Medical Contacts

*Physician*Physician Phone NumberAll starred items must be filled in. If an item is not applicable please type NA. Thank you!DentistDentist Phone NumberHospitalHospital Phone Number*Insurance*Insurance Phone NumberIf an item is not applicable please type NA. Typing NA states that the listed parents will be responsible for payment of medical care expenses NOt COVERED by my insurance.

Finished

Confirmation E-Mail address:

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Date of Last Upload: Wednesday, September 9, 2020 Student Enrollment Form

Student 1

Primary Family Information

Parent 1 Information

Parent 2 Information

Secondary Family Information

Parent 3 Information

Parent 4 Information

Contact Information (Other than parents)

Contact 1

Medical Contacts