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Nurturing Futures Academy

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Registration ID# 00912821SACC

NURTURING FUTURES ACADEMY

REGISTRATION

REGISTRATION FORM

AFTER SCHOOL (2.45pm - 5.45pm)

SUMMER CAMP (8.00am - 5.45pm)

CHILD INFORMATION

𝗙𝗶𝗿𝘀𝘁 𝗡𝗮𝗺𝗲

𝗠𝗶𝗱𝗱𝗹𝗲 𝗡𝗮𝗺𝗲

𝗟𝗮𝘀𝘁 𝗡𝗮𝗺𝗲

DOB MM/DD/YYYY

Street Address

Apt #

Home Phone #

Cell Phone #

Child Cell #

School Name

School Address

School Phone #

Homeroom Teacher

Siblings Attending Program

Does your child have health insurance? * Required

Yes

No

Health Insurance Provider

Does your child have or take any of the following? * Required

Yes

No

If so, please list them below:

𝗔𝗹𝗹𝗲𝗿𝗴𝗶𝗲𝘀:

𝗠𝗲𝗱𝗶𝗰𝗮𝘁𝗶𝗼𝗻:

𝗔𝘀𝘁𝗵𝗺𝗮 * Required

Yes

No

Medical Issues? * Required

Yes

No

If yes, will your child use an inhaler and/or medication during Afterschool? * Required

Yes

No

If any, state:

𝗥𝗮𝗰𝗲 / 𝗘𝘁𝗵𝗻𝗶𝗰𝗶𝘁𝘆 * Required

African-American

American-Indian

Asian-American

Pacific Islander

𝗥𝗮𝗰𝗲 / 𝗘𝘁𝗵𝗻𝗶𝗰𝗶𝘁𝘆 contd * Required

Caucasian / White

Spanish / Hispanic / Latino

Mixed Heritage

Other

PARENT / LEGAL GUARDIAN INFORMATION

𝗙𝗶𝗿𝘀𝘁 𝗡𝗮𝗺𝗲

𝗟𝗮𝘀𝘁 𝗡𝗮𝗺𝗲

Relationship

Day Phone #

Night Phone #

Cell Phone #

Email

Name of Employer

Phone #

Parent / Legal Guardian 2

Name

Relationship

Day Phone #

Night Phone #

Cell Phone #

Email

DOB MM/DD/YYYY

Documents to Upload

1. Child's Birth Certificate

Upload File