Enrollment

THE LEARNING TREE

Closing the Achievement Gap - Bridging the Digital Divide
SCIENCE - TECHNOLOGY - ENGINEERING - MATH

Full Name

Prefix

First Name

Middle Name

Last Name

Address

Date of birth

School info

Parent / Guardian 1

Guardian / Parent 2

Emergency contact

Persons authorize to pick up child

Health Survey

(To be completed by parent) Does your child have any of the following health conditions? Please check all that apply, give details, and note any limitations that would prohibit your child’s participation in specific activities.

Please indicate all important details and notes about the above checked ailments*
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.