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Application/Contract 1. Name Child/ren: 2. Age(s): 3. DOB: 4. Name of Parents/Guardians 5. Address: 6.

Application/Contract

1. Name Child/ren:

2. Age(s):

3. DOB:

4. Name of Parents/Guardians

5. Address:

6. Place of Employment and phone#:

7. Name of Doctor and Phone #:

8. Name of Insurance Company and Policy number:

9. Emergency Hospital of Choice:

10. Childs Allergies and Medications:

11. Emergency Contacts

1.

Name, Relationship, Address, Phone:

2.

3.

12. Please list all people authorized to pick up your child/ren:

13. Previous School/daycare and Phone#:

14. Transportation Authorization:

On occasion I will take the children for daily outings or field trips, the means of transportation

being my privately owned vehicle. Please fill out and sign below, this gives your child permission to join on the outings.

I give MSA Home Education permission to transport my child/ren on daily outings and field trips.

Initial

Date

15. Picture Authorization:

There are times when your child/rens picture may be taken during events, or for advertising purposes such as flyers, brochures, or the school website as long as it is first authorized by the parent. Please fill out and sign below, this gives permission for your child to be featured in publications and photographed.

I

my child/rens picture for school purposes.

give/do not give MSA Home Education permission to take

Initial

Date

16. Anything else I may need to know about your child. (ex. Special interests, hobbies, habits such as thumb sucking, nail biting ect, potty training needs, medical needs or diagnosed issues and favorite things)

17. My childs hours will be

to

18. I agree to pay

19. Acceptance of Terms and Signatures:

(hours)

per week for my child.

(days)

I have read and agree to comply with all the provisions and rules outlined in the Parent Handbook. I understand that this is a legal and binding contract and I have read everything carefully.

Parent Signature

Date

Directors Signature

Date