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2021-2022 MML Student Enrollment
Please fill out each question. All questions that are required have an asterisk.
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* Indicates required question
Last Name, First Name of Student
*
Your answer
Home Address - Number and Street
*
Your answer
City and Zip
*
Your answer
2020-2021 Grade Level (Current)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Parent Name
*
Your answer
Parent Email
*
Your answer
Parent Cell Number
*
Your answer
Student Lives With:
Both Parents
Both Parents Alternately
Mother Only
Father Only
Legal Guardian
Foster Parents
Special Court Instructions: If YES, please provide a copy to us.
Alternate Emergency Contact
*
In case we can't get hold of you in the event of an emergency, please enter the next person to contact and their phone number.
Your answer
Alternate Pickup/Dropoff Contacts
*
Please list below the full names and phone numbers of any relative or friend that you give permission to pickup your child.
Your answer
Medical Information
*
Please list below any Health Concerns or Medications that staff should be aware of regarding your child. Please include an allergies, treatments, medications, or other pertinent medical information.
Your answer
Physician Name
*
Your answer
Physician Phone
*
Your answer
Health Insurance Carrier
*
Your answer
Health Insurance Policy #
*
Your answer
Emergency Treatment: Do you authorize us to contact paramedics in the event of a medical emergency?
*
Yes
No
Required
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