Big Pine Academy

Enrollment Application

---

Student Information: Entering Grade: _____ Date of Enrollment:

Date of Birth: Sex:

SS#: ____________________________ Place of Birth:

City, State

Full Name:

Last First Middle Nickname

Child’s Address:

Family Information: Child Lives With:

Mother’s Name: Father’s Name:

Address: Address:

Home Phone: Home Phone:

Employer: Employer:

Address: Address:

Work Phone: Work Phone:

Cell#: Cell #:

E-mail address: E-mail address:

Family moved into Monroe County for first time: Month Year

Child first entered school in Monroe County: Month Year

School last attended: School address:

Medical Information:

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted for my child.

Doctor: Address: Phone:

Dentist: Address: Phone:

Hospital Preference:

Contacts: (Mandatory)

Child will only be released to the custodial parent or legal guardian and the persons listed below. The following people will also be contacted and are authorized to remove the child from the facility in case of illness, accident, or emergency, if for some reason the custodial parent or legal guardian cannot be reached:

Name Address Work# Home#

Name Address Work# Home#

Custody: Mother: _______ Father: _______ Both: _______ Other: _______

Special Needs:

Special Notations:

Medical Conditions:

Student Disclosures: Under Florida Statutes 232.0205, and district procedures, parents/guardians are required to note a student’s previous school expulsions, arrests resulting in a charge, and juvenile justice actions against the student. Please explain any expulsions, arrests or juvenile actions:

By signing below, you verify that all information on this form is complete and accurate; also, you fully understand and acknowledge that should any of this information change, that it is your responsibility to immediately notify the school in writing of any and all updates.

Signature of Parent Date