REGISTRATION FORM

SCHOOL YEAR 2011-2012

$60.00

Date________________________________ Grade to Enter_______________________________

Student Name___________________________________________________________________________

Last First Middle

Age of Child as of September 1, 2011 ________ Date of Birth______________

Street Address__________________________________________________________________________

Mailing Address_________________________________________________________________________

City________________________State____________________Zip________________________________

Home Phone #_____________________________Fax #_________________________________________

Father’s Name_____________________________Email Address_________________________________

Employer______________________________________________________________________________

Cell#___________________________ Work#______________________

Mother’s Name____________________________Email Address_________________________________

Employer______________________________________________________________________________

Cell#___________________________ Work#______________________

If parents are separated with whom does the child live?__________________________________________

Medical Information

Allergies_______________________________________________________________________________

Physical Restrictions _____________________________________________________________________

Other Medical Information________________________________________________________________

Emergency Contact Information

Responsible adult to contact if parents can not be reached:

Name_________________________________________________Phone #__________________________

Child’s Physician’s Name__________________________________Phone #_________________________

LIST OF PERSON(S) WHO HAS PERMISSION TO PICK CHILD UP

1._______________________________________ 2._________________________________________

3._______________________________________ 4._________________________________________

5._______________________________________ 6._________________________________________

PAYMENT PLAN

______Yearly (Full payment due August 10th)

_____10 Month (First payment due Aug. 10th)

_____11 Month (First payment due July 10th)

_____12 Month (First payment due June 10th)

STATEMENT OF COOPERATION

It is my understanding that the policy of the school is to make no refund on registration fees. I agree to pay tuition and other fees in accordance with schedule outlined by JTCS. Also, it is understood that no transcripts will be issued until all financial obligations are met. I also give permission for my child to take part in all school activities, including sports and school sponsored trips away from the school premises. Doing so, I absolve the school from liability due to any injury my child may sustain at school or during any school activity.

____________________________________ ____________________________________

Parent or Guardian Signature Date

Registration Check List

____Completed Registration Form ____Birth Certificate*

____Immunization Form* ____Registration Fee

____Textbook Fee

* If not already on file