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Urban Village Academy Registration Form
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* Indicates required question
Child's Name
*
Your answer
Date of Birth (MM/DD/YYYY)
*
Your answer
Medical Conditions/Allergies:
*
Your answer
Grade:
*
Junior Kindergarten
Senior Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Parent/Guardian Name:
*
Your answer
Parent/Guardian Phone:
*
Your answer
Parent/Guardian Email:
*
Your answer
2nd Parent/Guardian Name:
Your answer
2nd Parent/Guardian Phone:
Your answer
2nd Parent/Guardian Email:
Your answer
Previous School (if applicable):
Your answer
Does your child have an IEP or require additional support while at school?
*
Yes
No
Maybe
Home Address
*
Your answer
Emergency Contact 1 (Name and Phone Number)
Your answer
Emergency Contact 2 (Name and Phone Number)
Your answer
Authorized Pick Up 1 (Name and Phone Number if different than Emergency Contact)
Your answer
Authorized Pick Up 2 (Name and Phone Number if different than Emergency Contact)
Your answer
How did you hear about us?
*
Your answer
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