IBERO ACADEMY APPLICATION FORM SCHOOL YEAR 2011-2012 This information will be made available to Ibero Academy administrators and used for the parent directory and school mailing.
Student Information
Application date ______ / _____ / _____
Grade for which student is applying:_______________
Last Name________________________________
First Name_____________________________
Female ____
Date of Birth: _____ / _____ / __________
Male_____
Home Address________________________________________________________________________ Number Street Apt. # _______________________________________________________________________ City State Zip code Home Telephone_______________________________________________________________________
Family Information Parent´s full name:_____________________________________ Relationship to student:____________ Last First Middle Please check the correct form of address: Mr.__ Mrs.__ Ms.__ Dr.__ Prof.__ Other__________________ Address:____________________________________________________ Wireless phone:____________ Primary E-Mail Address (for school correspondence):__________________________________________ Employer: _____________________________________ Profession/Occupation:____________________ Address: _________________________________________________ Telephone: __________________ 1
Parent´s full name:_____________________________________ Relationship to student:____________ Last First Middle Please check the correct form of address: Mr.__ Mrs.__ Ms.__ Dr.__ Prof.__ Other__________________ Address:____________________________________________________ Wireless phone:____________ Primary E-Mail Address (for school correspondence):__________________________________________ Employer: _____________________________________ Profession/Occupation:____________________ Address: _________________________________________________ Telephone: __________________
Student lives with (check all that apply) Mother___
Father___
Stepmother___
Stepfather___
Guardian___
Other___
If necessary please provide the following information for additional parents/guardians: Parent´s full name:_____________________________________ Relationship to student:____________ Last First Middle Please check the correct form of address: Mr.__ Mrs.__ Ms.__ Dr.__ Prof.__ Other__________________ Address:____________________________________________________ Wireless phone:____________ Primary E-Mail Address (for school correspondence):__________________________________________ Employer: _____________________________________ Profession/Occupation:____________________ Address: _________________________________________________ Telephone: __________________
Parent´s full name:_____________________________________ Relationship to student:____________ Last First Middle Please check the correct form of address: Mr.__ Mrs.__ Ms.__ Dr.__ Prof.__ Other__________________ Address:____________________________________________________ Wireless phone:____________ Primary E-Mail Address (for school correspondence):__________________________________________ Employer: _____________________________________ Profession/Occupation:____________________ Address: _________________________________________________ Telephone: __________________
Check if appropriate: Mother is deceased___
Father is deceased___
Parents are separated___
Parents are divorced___ 2
Name(s) of sibling(s) and / or step-sibling(s), include age and school: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Student´s General Health
Birth Complications or Special Needs_______________________________________________________ Vision _____________ Hearing___________Allergies__________________________________________ Any other Health Condition: ______________________________________________________________ Student´s Physician ______________________________________________ Phone _________________ Address ______________________________________________________________________________ In case of an emergency, transport my child to: Hospital_______________________________________ Address_______________________________________________________ Phone_________________ In case of an emergency in which Parents cannot be reached, call: 1 ___________________________________________________________________________________ Name Relationship Phone 2 ___________________________________________________________________________________ Name Relationship Phone 3 ___________________________________________________________________________________ Name Relationship Phone Persons Authorized to Pick-Up my Child
The following are persons authorized to pick up my child from the school. I understand that my child will not be released to anyone not on this list. If it becomes necessary to make other arrangements for my child’s pick-up, I understand that I must notify Ibero Academy in advance in writing.
1 ___________________________________________________________________________________ Name Relationship Phone 2 ___________________________________________________________________________________ Name Relationship Phone 3 ___________________________________________________________________________________ Name Relationship Phone 3
Other Information
School Program Desired: Important: all students must be the required age by August 1
Program
Age
Time
Requirements
Toddlers
1 and 2
9:00 am - 1:00 pm
must walk
Pre-Kinder
3 and 4
9:00 am - 1:00 pm
________
Kinder
5
8:00 am - 3:00 pm
________
Elementary 1
6
8:00 am - 3:00 pm
________
Elementary 2
7
8:00 am - 3:00 pm
________
________
Clubhouse and Extended Day
Program
Time
Pre-Kinder
_____
1:00 pm - 3:00 pm
Pre-Kinder
_____
1:00 pm - 6:00 pm
Kinder
_____
3:00 pm - 6:00 pm
Elementary
_____
3:00 pm - 6:00 pm
Other Options (must be payed a week in advance)
Cafeteria Daily
_____
Cafeteria Other
_____
Transportation
_____
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General Permission Agreement
1. I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the school. I understand that any off school field trips require separate permission. 2. I hereby grant permission for my child to be included in evaluations, pictures, or media coverage connected with the school program, including the school’s official web site. 3. I hereby grant permission for the Principal or Acting Principal to take whatever steps may be necessary to obtain emergency medical care if warranted. These steps may include, but are not limited to, the following: a. Activate the Emergency Medical System by dialing 911 in any emergency situation. b. Attempt to contact a parent or guardian. c. Attempt to contact the child’s physician. d. Attempt to contact you through any of the persons listed on the emergency information forms you completed for us. e. If we cannot contact you or your child’s physician, we will do any or all of the following: f.
call another physician; (b) call an ambulance (if not already done): (c) have the child taken to an emergency hospital in the company of a staff member.
g. I understand that Ibero Academy is not responsible for any expenses incurred during the emergency transportation and treatment of my child. 4. By submitting this enrollment application, I hereby agree to comply with the policies of Ibero Academy regarding tuition and fees, attendance, health, carpool and parking, clothing, and procedures specified in the Parent Manual, monthly newsletters, and any other policy statements issued by the school each year. In addition, I understand failure to abide by the policies of the School may result in the termination of my child’s enrollment at Ibero Academy.
____________________________________________________ ________________________________ Parent/Guardian Signature Date
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