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Liberty Academy at the Priory Summer School Registration Form
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1. Name
Your answer
2. Gender:
Male
Female
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3. Date:
MM
/
DD
/
YYYY
4. Date of Birth:
MM
/
DD
/
YYYY
5. Age:
Your answer
6. School:
Your answer
7. Mother's Name/ Guardian:
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8. Mother's Address:
Your answer
9. Mother's Phone Number: Home and work
Your answer
10. Father's Name:
Your answer
11. Fathers address: (if different from mothers)
Your answer
12. Father's Phone Number Home and work
Your answer
13. Emergency Contacts / relation / phone: 1 and 2
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14. Other pickup persons: Names / relation / phone
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15. Please record any other information regarding the child's health or ability that you would want us to know about. Example asthmatic, allergies, disability etc
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16. Current School:
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Please note, cash payments only and this should be done in the Prep office.
17. Current Grade:
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