Changes to Student Registration Form
Please only complete the sections that you desire to update on your student's original registration forms. Sections left blank will remain unchanged on the original forms.

Excel Homeschool Academy
Registration for the 2023-2024 School Year
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Email *
Child's Name *
Child's Age *
Child's Sex
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Child's Home Address
Previous Year's Grade Level *
Parent/Guardian Name
Home Phone Number
Cell Phone Number
Work Phone Number
Email *
Place of Employment
Employment Address
Work Hours
CUSTODY/VISITATION ARRANGEMENTS
(Please provide any court-related documents in the case where visitation is restricted/prohibited of child's parent/guardian):
APPROVED EMERGENCY CONTACTS
(Those listed here are authorized to drop off and pick-up child with proper notification from parent/guardian and with valid ID)
EMERGENCY CONTACT #1:
INCLUDE NAME, RELATIONSHIP TO CHILD, PHONE NUMBER, AND HOME ADDRESS
EMERGENCY CONTACT #2:
INCLUDE NAME, RELATIONSHIP TO CHILD, PHONE NUMBER, AND HOME ADDRESS
EMERGENCY CONTACT #3:
INCLUDE NAME, RELATIONSHIP TO CHILD, PHONE NUMBER, AND HOME ADDRESS
MEDICAL INFORMATION
NAME OF CHILD'S DOCTOR:
DOCTOR'S PHONE NUMBER & ADDRESS:
PREFERRED HOSPITAL & PHONE NUMBER:
PLEASE LIST ALLERGY DETAILS BELOW ALONG WITH THE SIGNS AND SYMPTOMS OF AN ALLERGIC REACTION:
DOES YOUR CHILD HAVE AN EPI-PEN? (If yes, please provide one for the school to keep on-site.)
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Will your child require any medication to be taken while in the care of Excel Homeschool Academy? 
If yes, please list the name, dosage and reason for medication. 
All prescriptions must arrive in original packaging with child's name on it, along with a note from the doctor with instructions on how/when to administer.
ADDITIONAL NOTES FROM THE PARENT/GUARDIAN: 
Is there any additional information you would like us to know about your child that you feel would be beneficial?
By typing my name below, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that the information entered in this document represents the changes I desire to be made to my child's original Registration Form, and that the information given here is accurate and true, to the best of my knowledge. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian.
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A copy of your responses will be emailed to the address you provided.
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