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This is a student enrollment application. Please complete and submit this form to be considered for enrollment. It must be completed and submitted for all new students and updated yearly by current students.

Child Information(Required)
Enter the child's legal name.
Date of Birth(Required)
Enter the child's date of birth.
Home Address(Required)
Enter the physical address where the child lives.
Mother or Legal Guardian's Information(Required)
Enter the mother or legal guardian's name.
Enter the mother or legal guardian's date of birth.
MM slash DD slash YYYY
Home Address(Required)
Enter the mother or legal guardian's home address.
Enter the mother or legal guardian's cell phone number.
Email(Required)
Enter the mother or legal guardian's email address.
Enter the mother or legal guardian's employer's name or place of employment.
Employer's Address(Required)
Enter the mother or legal guardian's employer's physical address.
Enter the mother or legal guardian's employer's phone number.
Father or Additional Legal Guardian's Information
Enter the father or additional legal guardian's name.
Enter the father or additional legal guardian's date of birth.
MM slash DD slash YYYY
Home Address
Enter the father or additional legal guardian's home address.
Enter father or additional legal guardian's cell phone number
Email
Enter the father or additional legal guardian's email address.
Enter the father or additional legal guardian's employer's name or place of employment.
Employer's Address
Enter the father or additional legal guardian's employer's physical address.
Enter the father or additional legal guardian's employer's phone number.
Select who the child lives with.
Select whether a court has forbidden someone from having contact with the child. If you've answered "Yes", you must provide Little Duckling a copy of the court order detailing the restricted contact.
Emergency Contact
Enter the name of someone who may be contacted in the event of an emergency when the parent or legal guardian cannot be reached.
Enter the emergency contact person's relationship to the child.
Enter the emergency contact person's cell phone number to be called in the event of an emergency when the parent or legal guardian cannot be reached.
Pick Up Authorization 1
To ensure the safety of your child, please enter the name of an adult to whom your child may be released. Photo ID will be required to verify identity upon pick up.
Pick Up Authorization 2
To ensure the safety of your child, please enter the name of an adult to whom your child may be released. Photo ID will be required to verify identity upon pick up.
Pick Up Authorization 3
To ensure the safety of your child, please enter the name of an adult to whom your child may be released. Photo ID will be required to verify identity upon pick up.
Emergency Medical Contact Name(Required)
In the event of a serious accident or injury, we will immediately call 911 and administer First Aid or CPR. We will then call the parent/guardian immediately. If we are unable to reach a parent or guardian, we will contact the designated Emergency Contact Person.
Enter the emergency contact person's cell phone number.
Enter the name of your child's primary care physician.
Physician's Address
Enter the name of your child's dentist.
Dentist's Address
Enter the name of the hospital you want your child transported to in the event of a medical emergency. If emergency personnel transports your child to a different hospital based on medical need, you will be notified immediately.
Medical Information(Required)
Does your child have any of the following medical conditions? A medical condition does not exclude your child from care. Disclosing important medical information allows Little Duckling to provide the best level of care your child requires. If you indicate your child has a medical need, you must provide a doctor's statement with signature to Little Duckling detailing any special accommodations, medications, or instructions that are required to care for your child.
List any medications your student is required to take. A doctor's statement with signature must be submitted to Little Duckling.
Please provide any other information you feel will help Little Duckling provide care for your child or any concerns you may have related to your child's medical or developmental needs.
Photographic & Video Release(Required)
Little Duckling Early Learning Christian Academy has continuous interior and exterior video surveillance of its parking area, entryways, interior hallways, and each classroom. This surveillance is used for the protection and safety of its facility, staff members, visitors, students, and families on site. Video recorded through our surveillance system will not be shared with any unauthorized individual unless required through court order.
In the event of severe weather closings, special events, center closing reminders, or emergencies, Little Duckling wants to notify parents as soon as possible. Please provide a cell phone number for text notifications.
Urgent Email Notification(Required)
In the event of severe weather closings, special events, center closing reminders, or emergencies, Little Duckling wants to notify parents as soon as possible. Please provide an email address to receive messages.
Please provide a copy of your child's birth certificate.
Drop files here or
Max. file size: 50 MB.
    Please provide a copy of your child's CURRENT immunization record.
    Drop files here or
    Max. file size: 50 MB.
      Please provide a copy of your child's most recent physical dated within 1 year and signed by a physician.
      Drop files here or
      Max. file size: 50 MB.

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