Scholar Enrollment Application 2024-2025
Please fill out this application for your scholar. All spaces with a red asterisk are required information.
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Scholar Name: *
Parent/Guardian #1 Name: *
Parent/Guardian #1 Relationship *
Parent/Guardian#1 Home Number: *
ex. 901-555-5555
Parent/Guardian #1 Work Number :
ex. 901-555-5555
Parent/Guardian #1 Cellphone Number :
ex. 901-555-5555
Parent/Guardian Email #1:
Parent/Guardian #2 Name:
Optional
Parent/Guardian #2 Relationship
Optional
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Parent/Guardian #2 Home Number :
ex. 901-555-5555   Optional
Parent/Guardian #2  Work Number :
ex. 901-555-5555   Optional
Parent/Guardian #2  Cellphone Number :
ex. 901-555-5555   Optional
Does the student currently receive Special Education services under an Individualized Education Plan (IEP)? *
Does the student currently receive Special Education services under a 504 Plan? *
What grade will the student be entering in the 2024-2025 school year?   *
Did your scholar attend Pre-K in 2023 - 2024?
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How will your scholar be picked up from school? *
What school is your scholar transferring from? (Example: Shaw Elementary Memphis, Tennessee) *
How did you hear about MCP?
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Scholar T-shirt Size:
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Scholar's Date of Birth: *
MM
/
DD
/
YYYY
Address: *
ex. 123 Mane Street, Memphis, TN 38106
Gender *
Social Security Number:
ex. xxx-xx-xxxx
Scholar Age: *
Emergency Contact #1 Name *
Please list a person we can contact in case of an emergency if a parent/guardian cannot be reached. A contact person would be someone who lives in the neighborhood or is otherwise readily available. By listing this person you are also authorizing them to pick up your scholar from school in an emergency.
Emergency Contact #1 Number *
Emergency Contact #1 Relationship *
Emergency Contact #2 Name *
Please list a person we can contact in case of an emergency if a parent/guardian cannot be reached. A contact person would be someone who lives in the neighborhood or is otherwise readily available. By listing this person you are also authorizing them to pick up your scholar from school in an emergency.
Emergency Contact #2 Number *
Emergency Contact #2 Relationship *
Child Pickup Authorization #1 Name
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #1 Number
Child Pickup Authorization #1 Relationship
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Child Pickup Authorization #2 Name
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #2 Number
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #2 Relationship
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Child Pickup Authorization #3 Name
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #3 Number
Child Pickup Authorization #3 Relationship
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Child Pickup Authorization #4 Name
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #4 Number
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #4 Relationship
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Child Pickup Authorization #5 Name
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #5 Relationship
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Child Pickup Authorization #6 Name
This individual has my permission to pickup my child from school. Any adult picking up a child must show their identification. Emergency Contacts and Parents listed on the previous questions will be given authorization to pickup. You DO NOT need to write them again here.
Child Pickup Authorization #6 Number
Child Pickup Authorization #6 Relationship
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Special Remarks or Concerns
i.e. court orders, daycares, after school pickup alternatives
Medical Information: Pediatrician Name
Medical Information: Pediatrician Number
Medical Information: Pediatrician Address
Medical Information: Insurance Company Name
Medical Information: Insurance Policy Holder
Medical Information: Insurance Policy Number
Medical Information: Insurance Group Number
Medical Information: Medication Allergies
Medical Information: All Other Allergies
My child has an epi pin
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Health Conditions
Please check the box if your scholar has any of the following health conditions below. If it is not listed please use the "Other"  spot to type in the health condition
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