Child's Full Name: (required)
Nickname:
Date of Birth:
Age:
Does your child have any allergies or medical conditions?
Please list the name and contact information of your child's primary care physician.
Are there any fears or dislikes we should be aware of?
What are your child's favorite activities or interests?
Does your child currently have any emotional difficulties to which we should be sensitive?
What are the names and ages of your child's siblings?
Which hand does your child use?
Has your child ever had a serious illness?
What would you like your child to gain from this school?
Do you have any additional comments or suggestions?
Mother's Name:
Address:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Email:
Father's Name:
Address:
Home Phone:
Cell Phone:
Work Phone:
Employer:
Email:
Authorized Individuals
Individuals, other than parents, who are authorized for pick-up and emergency contact:
Person 1:
Relation to Child:
Phone:
Person 2:
Relation to Child:
Phone:
Person 3:
Relation to Child:
Phone:
PARENT CONTRACT
I have read the Policy and Procedures of Atlas Academy and agree to abide by these terms as prescribed herein.
We have read the Policies & Procedures of Atlas Academy and agree to abide by them. We understand that to be considered for enrollment a $100 registration fee must accompany this application. This fee is non-refundable unless the desired class is full when this application is processed. This contract for enrollment is for the full school year. For your convenience, the tuition may be paid in nine equal monthly installments. This will be due by the 5th of each month. A late fee of $25.00 will be charged after the 10th day of each month. If withdrawal is required because of relocation, tuition for future months will be waived. Failure to pay will result in accounts being sent to third party collection. All costs related to collect will be at the parents' expense.
As a participant (child) or parent in this school, I recognize and acknowledge that there are certain risks of physical injury and I voluntarily agree to assume the full risk of any injury, damages or loss, regardless of severity, that my minor or I may sustain as a result of participating in any and all activities connected with or associated with this school. I authorize Atlas Academy staff to administer emergency first aid in the event of an injury.
Please review and sign the Parent Contract for your child's enrollment.
