ATLANTA PREPARATORY

ENROLLMENT FORM

ENTRANCE DATE

WITHDRAWAL DATE


CHILD’S NAME
CHILD’S DATE OF BIRTH AGE SEX
HOME ADDRESS (STREET) APT/PO BOX
CITY STATE ZIP CODE
HOME PHONE NUMBER


CHILD’S NAME
CHILD’S DATE OF BIRTH AGE SEX
HOME ADDRESS (STREET) APT/PO BOX
CITY STATE ZIP CODE
HOME PHONE NUMBER


CHILD’S NAME
CHILD’S DATE OF BIRTH AGE SEX
HOME ADDRESS (STREET) APT/PO BOX
CITY STATE ZIP CODE
HOME PHONE NUMBER


CHILD’S NAME
CHILD’S DATE OF BIRTH AGE SEX
HOME ADDRESS (STREET) APT/PO BOX
CITY STATE ZIP CODE
HOME PHONE NUMBER


CHILD’S NAME
CHILD’S DATE OF BIRTH AGE SEX
HOME ADDRESS (STREET) APT/PO BOX
CITY STATE ZIP CODE
HOME PHONE NUMBER


FATHER’S NAME HOME PHONE
FATHER’S ADDRESS (IF DIFFERENT FROM CHILD’S)
STREET CITY STATE ZIP CODE
FATHER’S PLACE OF EMPLOYMENT
EMPLOYER’S ADDRESS (STREET)
CITY STATE ZIP CODE
WORK PHONE ALTERNATE PHONE


MOTHER’S NAME HOME PHONE
MOTHER’S ADDRESS (IF DIFFERENT FROM CHILD’S)
STREET CITY STATE ZIP CODE
MOTHER’S PLACE OF EMPLOYEMENT
EMPLOYER’S ADDRESS (STREET)
CITY STATE ZIP CODE
WORK PHONE ALTERNATE PHONE

CHILD’S LIVING ARRANGEMENTS: (CHECK ONE) BOTH PARENTSMOTHERFATHEROTHER

CHILD’S LEGAL GUARDIAN(S): (CHECK ONE) BOTH PARENTSMOTHERFATHEROTHER

THE CHILD MAY BE RELEASED TO THE PERSON(S) SIGNING THIS AGREEMENT OR TO THE FOLLOWING:


NAME ADDRESS (STREET)
CITY STATE ZIP CODE
PRIMARY PHONE ALTERNATE PHONE
RELATIONSHIP TO THE CHILD
RELATIONSHIP TO THE GUARDIAN OR PARENT(S)
ADDITIONAL IDENTIFYING INFORMATION (IF ANY)


NAME ADDRESS (STREET)
CITY STATE ZIP CODE
PRIMARY PHONE ALTERNATE PHONE
RELATIONSHIP TO THE CHILD
RELATIONSHIP TO THE GUARDIAN OR PARENT(S)
ADDITIONAL IDENTIFYING INFORMATION (IF ANY)


PERSONS TO CONTACT IN THE CASE OF EMERGENCY OR WHEN PARENT(S) OR GUARDIAN CANNOT BE REACHED:
NAME PHONE
NAME PHONE
NAME PHONE


NAME OF PUBLIC/PRIVATE SCHOOL CHILD ATTENDS (IF ANY)
CHILD’S DOCTOR’S OFFICE/CLINIC NAME
PHYSICIAN’S NAME PHONE


My child has the following special needs:

The following special accommodation(s) may be required to most effectively
Meet my child’s needs while at the center:

My child is currently on medication(s) prescribed for long-term continuous use
and/or has the following pre-existing illness, allergies, or healthconcerns:


With signing this application, you give us permission to use images of your child for website, videos, social media and advertising purpose

Emergency medical authorization
Should (child’s name) Date of birth

Suffer an injury or illness while in the care of atlanta preparatory school of
the arts and the facility is unable to contact me (us) immediately, it shall be
authorized to secure such medical attention and care for the child as may be
necessary. i (we) shall assume responsibility for payment for services rendered.
parent/guardian

DATE

FACILITY ADMINISTRATOR/PERSON IN CHARGE

DATE

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