Gospel Tabernacle Academy

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Application for Remote Learning Care Program

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Student Information *

Full Name of Child

Age *

Birthdate *

YYYY

Gender

Male

Female

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Social Security # *

Address, City, State, Zip Code *

Phone # *

Does Your Child have Any Allergies? *

Yes

If yes, please describe

Is your child on any continuous medication? *

Yes

If yes, please describe

Please give any information concerning your child which will be helpful in his/her experience in a group setting.

Such as eating, play, and sleeping habits, likes, dislikes, and fears.

Photo/Video Release Form *

GTA has permission to use my child's photograph and/or video images publicly to promote GTA and advertise school activities. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand. that no royalty, fee, or other compensation shall become payable to me by reason of such use.

Yes

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