Student Registration 2023-2024
Excel Homeschool Academy
Registration for the 2023-2024 School Year
Sign in to Google to save your progress. Learn more
Email *
Child's Name *
Child's Age *
Child's Birthday *
Child's Sex *
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.)
 *
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?
 *
BEFORE & AFTER SCHOOL CARE *
Please indicate the typical days and times you will require before/after school care. (If days/times need to change, please let the school know as soon as possible). *
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 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.
 *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms