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Please fill out and submit the form below.
REGISTRATION FORM
Your Name prefix, Mr or Mrs?
Registration Form
Your E-mail *
Program: *
Micro-school Assistance
Homeschool Assistance
Academic After-care
Tutoring
Grade Level *
Student(s) Name(s) (Last, First, and Middle.)
Today's Date *
Enrollment Date *
Date of Birth *
Date of Birth (Student #2)
Sex: *
Address (Street, City, State, Zip)
List of known Allergies/Dietary Restrictions:
Student(s) live with: *
Both Parents
Mother
Father
Guardian
Parent/Guardian Information
Mother's Information
Mother's Name
Mother's Email
Mother's Cell Number
Mother's Work Number
Father's Information
Father's Name
Father's Email
Father's Cell Number
Father's Work Number
Guardian's Information
Guardian's Name
Guardian's Email
Guardian's Cell Number
Guardian's Work Number
Physician Information
Student(s) Physician *
Office Name/Address
Physician Email *
Physician Phone Number: *
May the facility consult the above physician if parent/guardian cannot be reached? *
Yes
No
Other person(s) to be notified in case of illness or accident:
Person #1:
Name
Relationship
Address
Phone
Person #2:
Name
Relationship
Address
Phone
Person #3:
Name
Relationship
Address
Phone
Persons permitted to remove child from school facility:
Mother *
Yes
No
Father *
Yes
No
Guardian *
Yes
No
Other person(s) permitted to remove child from school facility:
Person #1:
Name
Relationship
Address
Phone
Person #2
Name
Relationship
Address
Phone
Person #3
Name
Relationship
Address
Phone
Any individual permitted to remove a child from Fundamental Academy must set up their profile in our enhanced security system.
Name of person enrolling student(s): *
Date of Enrollment *
Your message
Electronic Signature (Enter your full name) *
Send message
(*) Required fields
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