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Enrollment Registration
Website:
www.mclacademy.com
Address: 845 West College Street, Suite B, Murfreesboro, TN 37129
Contact us at (615) 900-1582 or mcla.advertisement@gmail.com
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* Indicates required question
Mother's/Caregiver Name
*
Your answer
Mother's/Caregiver Address (City, State, Zip)
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Your answer
Mother's/Caregiver Phone Number
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Your answer
Mother's/Caregiver Email
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Your answer
Mother's/Caregiver Employment (N/A)
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Your answer
Mother's/Caregiver Employment Address (City, State, Zip)
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Your answer
Mother's/Caregiver Employment Phone Number
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Your answer
Father's/Caregiver Name
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Your answer
Father's/Caregiver Address (City, State, Zip)
*
Your answer
Father's/Caregiver Email
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Your answer
Father's/Caregiver Phone Number
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Your answer
Father's/Caregiver Employment or (N/A)
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Your answer
Father's/Caregiver Employment Address (City, State, Zip)
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Your answer
Father's/Caregiver Employment Phone Number
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Your answer
How may children (siblings) need MCLA child services?
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1
2
3
4
Child 1 Full Name
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Your answer
Child 1 Nickname
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Your answer
Child 1 Previous/Current School (if applicable).
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Your answer
Are the child 1's immunization records housed at the school above?
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Yes
No
Unsure
Child 1| if no, list the school where the records are housed.
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Your answer
Child 1 | Name Agency and Agency Address if applicable.
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Your answer
Child 1 DOB
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MM
/
DD
/
YYYY
Name of Physician
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Your answer
Physician Address and (City, State, and Zip)
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Your answer
Physician Number
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Your answer
What are some ways the child plays at home?
Your answer
Does he/she play with children from other families?
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Yes
No
Does he/she react when he/she does not get his/her own way?
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Yes
No
Is the entire family together for any time during the day?
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Yes
No
What time does the child eat? (Breakfast, Lunch, Dinner)
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Your answer
Does the child have in between meals? (snacks)
Yes
No
Clear selection
Does the Child feed him/herself?
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Yes
No
What is the child's general attitude towards eating (picky, eats a lot...)
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Your answer
If the child refuses to eat, how is it handled and by whom?
Your answer
Child 2 Full Name
Your answer
Child 2 Nickname
Your answer
Child 2 Previous/Current School (if applicable).
*
Your answer
Are the child 2's immunization records housed at the school above?
*
Yes
No
Unsure
Child 2 | if no, list the school where the records are housed.
*
Your answer
Child 2 | Name Agency and Agency Address if applicable.
*
Your answer
Child 2 DOB
MM
/
DD
/
YYYY
Name of Physician
*
Your answer
Physician Address and (City, State, and Zip)
*
Your answer
Physician Number
*
Your answer
What are some ways the child plays at home?
Your answer
Does he/she play with children from other families?
*
Yes
No
Does he/she react when he/she does not get his/her own way?
*
Yes
No
Is the entire family together for any time during the day?
*
Yes
No
What time does the child eat? (Breakfast, Lunch, Dinner)
*
Your answer
Does the child have in between meals? (snacks)
Yes
No
Clear selection
Does the Child feed him/herself?
*
Yes
No
What is the child's general attitude towards eating (picky, eats a lot...)
*
Your answer
If the child refuses to eat, how is it handled and by whom?
Your answer
Child 3 Full Name
Your answer
Child 3 Nickname
Your answer
Child 3 Previous/Current School (if applicable).
*
Your answer
Are the child 3's immunization records housed at the school above?
*
Yes
No
Unsure
Child 3 | if no, list the school where the records are housed.
*
Your answer
Child 3 DOB
MM
/
DD
/
YYYY
Name of Physician
*
Your answer
Physician Address and (City, State, and Zip)
*
Your answer
Physician Number
*
Your answer
What are some ways the child plays at home?
Your answer
Does he/she play with children from other families?
*
Yes
No
Does he/she react when he/she does not get his/her own way?
*
Yes
No
Is the entire family together for any time during the day?
*
Yes
No
What time does the child eat? (Breakfast, Lunch, Dinner)
*
Your answer
Does the child have in between meals? (snacks)
*
Yes
No
Does the Child feed him/herself?
*
Yes
No
What is the child's general attitude towards eating (picky, eats a lot...)
*
Your answer
If the child refuses to eat, how is it handled and by whom?
*
Your answer
Dietary restrictions for each child.
*
None
for Child 1
for child 3
for child 2
Vegetarian
Vegan
Kosher
Gluten-free
Other:
Required
List specifics child 1's favorite food, food allergies, or food dislikes.(Or N/A)
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Your answer
List specifics child 2's favorite food, food allergies, or food dislikes. (Or N/A)
Your answer
List specifics child 3's favorite food, food allergies, or food dislikes. (Or N/A)
*
Your answer
List all siblings (MCLA or Non-MCLA Children)
Your answer
I understand that I will have to pay $$ an annual registration fee.
*
Yes
No
Required
Please list any other adults to whom your child may be released or are authorized to provide transportation for your child.
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Your answer
Will the child be transported by the agency?
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Yes
No
If yes, please check all that apply.
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To School
From School
To Home
From Home
Field Trips - Only with prior written permission for each. off-site activity.
N/A
Required
Emergency Contact Name
*
Your answer
Emergency Contact Number
*
Your answer
Emergency Contact Email
*
Your answer
Emergency Contact Address, City, State, and Zip
*
Your answer
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