Tiger Academy Enrollment

2019 - 2020

Starting Date: _______Grade Entering: ________

Student’s Name: __________________ Gender: ____ Birthdate: _________

Address (Street, City, State, Zip): ________________________________

Email:_______________

Mother’s/Guardian’s Name: ____________________________

Home Phone: ______________ Cell Phone: _______________E-Mail___________________

Address (if not the same as STUDENT’S):______________________________

______________________________

Employer: ___________________________

Work Phone: _________________________

Father’s/Guardian’s Name: ____________________________

Home Phone: ______________ Cell Phone: _______________E-Mail___________________

Address (if not the same as STUDENT’S):______________________________

______________________________

Employer: ___________________________

Work Phone: _________________________

Emergency Contact #1 Name: ___________________________________

Relationship : _________________ Home Phone: ______________

Cell Phone: _______________ Work Phone: _________________

Emergency Contact #2 Name: ___________________________________

Relationship : _________________ Home Phone: ______________

Cell Phone: _______________ Work Phone: _________________

PLEASE CIRCLE WHICH DAYS YOUR STUDENT WILL ATTEND

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

NAMES OF SIBLING/S:__________________________________________________________________

1stASAP

Kinsley Murray F 7/3/2014171 White River Mtn Blvd # 208 Hollister, MO

jmue8908@gmail.com

Jamie Murray816-304-9042 jmue8908@gmail.com

Cox Medical Center Branson417-348-8406

N/A

John MurrayGrandpa

314-504-7520

Elizabeth BallardGrandma

314-504-2615

Tiger Academy Health Form/Permissions

Student/s Name: __________________ Gender: ____ Birthdate: _________

Please check the statement that applies;

__ My student is in good health, is able to participate in group

care, has no special health or medical requirements.

__ My student is able to participate in group care, but has spe-

cial health or medical requirements as listed below.

Please list any allergies, special medical conditions, including

chronic health problems (such as asthma, seizures), behavioral dis-

orders, special needs, etc.

Your signature below indicates your consent for your student to partici-

pate in all field trips Tiger Academy will be taking in the 2019-2020 school

year. It also indicates that you understand that if any injury occurs, Tiger

Academy will make every reasonable effort to contact you for permission.

In the event of injury, you authorize Tiger Academy to give

consent for your student to receive emergency medical aid should the

treatment be medically necessary.

___________________________________

Parent/Guardian Signature

Kinsley Murray F 7/3/2014