All questions in the form are important for the student's health and safety. Please make best efforts to fully complete this form.

A. Student Information

First Name Middle Name Last Name Male Female Birthdate Grade (Select one) Montessori Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th  Bus/Parent   Address City   Zip Code Home Phone

B. Parents' Contact Information

Father's Name Mother's Name   Employer Employer   Work Phone Work Phone   Cell Phone Cell Phone   Email Email

C. Student lives with:

Mother Guardian (Guardian Name)   Father Other (Other Name)

D. Custodial Release Consent

Students will be released only to parents or emergency alternates. If a custody agreement is in effect, may the child be released to the non-custodial parent? N/A Yes No

E. Other Contact(s) if parent/guardian can not be reached.

1. Full Name 2. Full Name   Home Phone Home Phone   Alternate Phone Alternate Phone   Relationship Relationship

F. Doctor/Hospital Information

Doctor Preferred Hospital Phone Insurance Provider

If emergency treatment is required and neither parent(s) nor emergency alternate(s) can be reached, the school authorities will use their judgment in securing the services of the medical facility most accessible. Ambulance cost is your responsibility. Parent/guardian must be at the hospital to assure medical treatment.

G. Medical Information

List any medical condition. Medication(s) Taken at home   Allergy to any drug, insect bite, food or other substance. Describe if any. Hospitalization or illness during past year. Hosp. Date

May the school nurse share medical information on an "as needed" basis for the student's health and safety? Yes No A doctor's note is required for all presciption medication. A doctor’s note is required for over the counter medication other than those written below.

The school nurse may administer: Aceteminophen (generic Tylenol) Yes No Ibuprofen (generic Advil) Yes No Benadryl for allergic reaction Yes No

H. Milk Order

I wish to have my child receive milk in school at lunchtime. 1st Semester - $45 2nd Semester - $45 Full - $90 None

I. Student Consent

I hereby give my consent for my child to take part in all Field Trips organized by the school. Yes No I hereby give my consent for my child’s photograph to be used in local newspapers, on the Armenian Sisters Academy website and internet social media sites for the purposes of public relations. Childrens' names will not be identified on the internet. Yes No State Law (Act 195) authorizes the loan of textbooks by the Secretary of Education to children enrolled in nonpublic schools. Act 90 authorizes the loan of instructional materials. Our school is now in the process of requesting the specific textbooks and materials to be loaned to your children. The law requires, however, that a parent of each child attending the nonpublic school individually request a loan of the textbooks. (This law is applicable to Pennsylvania residents only.) Please click here to acknowledge you read and understand this.

J. Fund Raising

Will you participate in fund raising? Yes No ($200 Fund Raiser Donation in lieu of Participation)

(Please verify all fields before submitting.)