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Full Name
*
Prefix
First Name
Middle Name
Last Name
Address
*
Address Line 1
Address Line 2
City
State
Zip Code
Ward
Date of Birth
*
Address Line 1
Address Line 2
Date of Birth
Age
Zip Code
Country
School info
*
School Name
Teacher
Grade
State
Zip Code
Country
Parent/Guardian
Parent/Guardian 1
*
Mother/Father
Address Line 2
Home Phone
Work Phone
Cell Phone
Email
Parent/Guardian 2
*
Mother/Father
Address Line 2
Home Phone
Work Phone
Cell Phone
Email
Emergency Contact
*
Name
Relationship
Home Phone
Work Phone
Cell Phone
Email
Persons Authorized to Pick up Child
*
Address Line 1
Address Line 2
Name
Relationship
Name
Relationship
Childs Health Information
Please let us know any important information regarding your child.
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Check Box
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Asthma
Seizures
Diabetes
Epilepsy
Hearing Impairment
Heart Condition
Visual Impairment
Food Allergies
Environmental Allergies
Plant/Animal Allergies
Insect Bite Allergies
Behavioral Issues
Emotional Challenges
Physical Challenges
Please indicate all important details and notes about the above checked ailments
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Does your child use or carry an Inhaler or an EpiPen? If so please give details and instructions for use?
*
Does your child wear a corrective device? (glasses, hearing aid, etc.)
*
Please provide us with the name and phone number of your child’s doctor.
*
Doctors Name
Phone Number
City
State
Zip Code
Country
Parent/Guardian Digital Signature
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Security Code
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The Learning Tree, Inc.
Closing the Achievement Gap ~ Bridging the Digital Divide
SCIENCE ~ TECHNOLOGY ~ ENGINEERING ~ MATH
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