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Students Full Legal Name______________________________________________

                                       Last Name              First                         Middle                   SS#

Birth date _________         Sex:      Male/Female     Nickname ___________________  

Age ____    _____       Place of Birth___________  Family Church Preference __________
       Years       Months 

For Seventh-day Adventist Students only:            Which church are you a member of?

Father ___________________________Yr. baptised_______

Mother __________________________Yr. baptisted_______

Child ____________________________Yr. baptised ______

 

Parent/Guardian #1____________________________________________________________________________

 

Address #1  ____________________________________________________________________

                   Street                                City/State              Zip             Billing E-mail Address

Phone  _________________________________________________________________________

                   Home                             Business                               Cell                            FAX      

Business #1 _____________________________________________________________________

                    Occupation                                           Employed By

 

Parent/Guardian #2________________________________________________________________

                                Last Name                         First                     Middle                   S.S.#

Address #2   ____________________________________________________________________

                     Street                             City/State              Zip         Alternate E-mail Address

Phone   #2 ______________________________________________________________________

                     Home                             Business                         Cell                                  FAX

Business #2 ____________________________________________________________________

                   Occupation                                           Employed By

Emergency Call   
1. ___________________________________________________________________

     Person other than parent    Home Number                 Cell             Work

2. ___________________________________________________________________

     Person other than parent    Home Number                 Cell             Work

 

Authorized escorts in case parent cannot be reached.
Name _______________Address ______________Home Phone ____________ Cell __________ 

Name _______________ Address _____________Home Phone _____________ Cell __________
 

 

 

I would like to contract for the following services:     Requested school-start date for child:___________

    

Elementary School -  Grade entering _______________

            Last school attended _______Grade last year______Teacher___________________

1.         Pre/Kindergarten - ½ day am       _____             (5 yr. old by Oct. 1) 

                        Pre/Kindergarten - full day           _____                  

 

2.         Kindergarten - ½ day am         _____             (5 yr. old by Sept. 1) 

Kindergarten - full day             _____

 

3.         Pre-First (full day)                   _____             (6 yr. old by Oct. 1)

          4.        Pm Kindergarten (12-3:30pm) _____             (enrolled at public am Kindergarten)

1. Preschool Only: (Half-day, 8:30 a.m. to 12:30 noon)   M__ T__ W__Th__ F___

2. Preschool and Child Care (Full-day, 7:00 a.m. to 6:00 p.m.*) M__ T__ W__Th__ F___

 

Child care (all ages)     7am - 8:30am, Noon - 6pm or 3:30pm - 6pm

 

I will need my child picked up from Eagle Hills:                         am ______   pm_______

1.   Before school care: M __ T __ W __ Th __ F __ As Needed ___ (7am-8:30am)

2.   After school care:   M___ T___ W__ Th___ F__As Needed ___ (3:30pm-6pm)

            3.   Summer care:          M____T____W____Th____F____As Needed ____

 

 

I found out about this school through:   TV ___ Radio ___  Yellow pages ___ Magazine ___

            (Please check all that apply)                          Pamphlet __ Mail __ Friend (Name)_________________

 

Idaho law (Idaho Code 18-8327 and 18-8414) prohibits the Eagle Adventist Christian School & Child-Care Center, from employing, using as volunteers, or allowing any person on the premises who is registered or required to be registered under the sex offender mandatory registration requirements of Idaho law. The only exception to this prohibition is that such person shall be allowed to drop off and pick up that person's own child or children. If you are presently registered or required to be registered under Idaho sex offender mandatory registration requirements, you must adhere to these restrictions and you have a duty to notify us so that we can assist you in meeting these restrictions. By signing below, you verify that you are not subject to such registration requirements. If you are subject to such registration requirements, please note this on this form prior to signing.

______________________    ________            ________________________     ________

Signature of Father/Guardian           Date              Signature of Mother/Guardian    Date

__________________________________       ________________________

Signature of Director/Principal                                Date accepted

We, the under signed parents or guardian of __________________________________, a minor,

do hereby consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment

and hospital service that may be rendered to said minor under the general or special instructions of

___________________________________, M. D., (phone # ______________) or any physician the

school or organization may call, whether such diagnosis or treatment is rendered at the office of said

physician or at a licensed hospital. It is understood that reasonable effort will be made to contact the

doctor listed above before any other physician is called by the school or other organization.

It is further understood that this consent is given in advance of any specific diagnosis or treatment

which might be required and is given to authorize EAGLE ADVENTIST CHRISTIAN SCHOOL,

PRESCHOOL AND CHILD CARE CENTER or the physician to exercise the best judgment as

to the requirements of such diagnosis or treatment.

 

This consent shall remain in continuous effect until revoked in writing and delivered to the physician

named above and to the school or organization entrusted with the custody of said minor.

 

We hereby authorize any hospital, physician, or other person who has attended or examined the minor

to furnish to CHRISTIAN EDUCATORS INSURANCE TRUST, through it's representative, at the
IDAHO CONFERENCE OF SEVENTH-DAY ADVENTISTS any and all information with respect
to any illness,medical history, consultation, prescriptions or treatment, and copies of all hospital or
medical records. This release authority applies to any information governed by the Health Insurance
Portability andAccountability Act of 1996 (HIPPA), 42 U.S.C. 1320d and 45 CFR 160 through 164. 
A Photostat copyof this authorization shall be considered as effective and valid as the original.

 

MY CHILD IS ALLERGIC TO THE FOLLOWING FOODS / MEDICATIONS: _________________________________________________________________________                 
Date     Signature of Father                                                               

_______________________________________     Date____________________________

Signature of Mother                                                            

_______________________________________     Date ____________________________

Signature of Legal Guardian                                               

_______________________________________     Date ____________________________

Witness

Phone #s where we can be reached ________________________________________________________

Medical insurance company_________________________Phone__________________

Address_______________________________________Group number____________

Name of insured____________________   Insured ID# __________________________

I verify that the information listed is complete an accurate. 

______________________________                        _________________

Signature of parent/guardian                                          Date

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