Date:_____________________ Home Phone:__________________

Child's Full Name:____________________________ Child's Nickname:__________________

Child's Birth Date:______________ Age:_____________ Sex:______________

Address 1:_________________________ Address 2:________________________________

City/State/Zip:________________________________________________________________

Child's Hobbies and Interests:____________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Father's Name:___________________________ Education:___________________________

Occupation:_________________________________________________________________

Employer:______________________________ Business Phone:_______________________

Mother's Name:__________________________ Education:___________________________

Employer:______________________________ Business Phone:________________________

Marital Status of Parents:___________________ Religious Preference:____________________

Mother/Father's Address:_______________________________________________________

Sibling(s) & Ages:_____________________________________________________________

 

If child is not living at home of parents - list name, address and home phone number of responsible adult below. ________________________________________________________________________________________________ Employer:______________________________ Business Phone:______________________

 

If you cannot call for your child, please give names of persons to whom child can be released. Name:___________________________________ Phone:__________________________ Name:___________________________________ Phone:__________________________

How did you hear about our school?_______________________________________________

___________________________________________________________________________

Has your child ever attended a private school program before? ______Yes ______No

If so. . .When:________________________ Where:_________________________________

How long do you plan to keep you child at Brisbane Academy? __________________________

Has your child received any formal testing/counseling? If so, please include or attach information.

_________________________________________________________________________

_________________________________________________________________________

Please use back of application for any additional notes.

 

INFORMATION ABOUT YOUR CHILD

Does your child have any known allergies? ____Yes ____ No.  If so, please list them__________

___________________________________________________________________________

___________________________________________________________________________

Does your child have any special dietary needs? ____Yes ____No If so, please list them_______

___________________________________________________________________________

___________________________________________________________________________

Please list any special conditions or disabilities.________________________________________

___________________________________________________________________________

___________________________________________________________________________

Child's Doctor:______________________________ Office Phone:_______________________

Office Address:_______________________________________________________________

Child's Dentist:______________________________ Office Phone:_______________________

Office Address:_______________________________________________________________

Hospital Preferences:___________________________________________________________

 

Name, Address & Phone of 2 Persons We May Contact In Case of Emergency Name:_________________________________ Relationship:________________________ Address:______________________________________ Phone:_____________________ Name:_________________________________ Relationship:________________________ Address:______________________________________ Phone:_____________________

I agree that the Brisbane School Representative in charge may authorize the physician of his/her choice to provide emergency care for my child in the event that neither I nor the family physician, family dentist or other aforementioned authorized care provider can be contacted immediately.

Date:______________ Signature of Parent______________________________________

Please Use The Backs of these APPLICATION FORMS to provide us with any other information that you consider pertinent.

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