Mother/Guardian Full Name
*
First Name
Last Name
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone
*
(###)
###
####
Occupation
*
Employed By:
*
Work Phone
*
(###)
###
####
Work Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Work Hours
*
Email
*
Marital Status
*
Married
Single
Divorced
Separated
Widowed
Father/Guardian Name
First Name
Last Name
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone
(###)
###
####
Occupation
Employed By:
Work Phone
(###)
###
####
Work Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Work Hours
Email
Marital Status
Married
Single
Divorced
Separated
Widowed
Childs Full Name
*
First Name
Last Name
Name Child Prefers to be Called:
*
Childs Age
*
Child's Birthday
*
MM
DD
YYYY
Gender
*
Male
Female
Has Your Child been in Childcare in the Past?
*
Yes
No
Allergies
Medications
Existing Illness (if any, please explain)
Serious Injury or Illness in Past 12 Months (if any, please explain)
Physician's Name
First Name
Last Name
Physician's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Physician's Phone
(###)
###
####
Hospital
Hospital Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Hospital Phone
(###)
###
####
What kind of learner would most describe your student:
*
Independent, Group, Mentored)
In which subject has your student demonstrated the most success?
*
In which subject has your student demonstrated the most interest?
*
In which subject has your student demonstrated the least success?
*
In which subject has your student demonstrated the least interest?
*
Describe how your student handled public school on a social level:
*
Works well with others, Little to no conflict, some conflict, lots of conflicts, fighting
Describe your student's relationship with teachers:
*
little to no problems, teacher's pet, nothing but positive feedback, lots of negative feedback, lots of time in the principal's office
What extracurricular subjects does your student find most enjoyable?
*
Describe your students attitude towards school and education:
*
Where does your student appear to find themselves in settings with other students?
*
The leader, Makes some attempts to lead, Isolated, Follows other's lead
What were your student's grades the last semester of their last year of school:
*
Please list all classes and grades
Describe the consensus that was achieved during the combination of all the teacher/parent conferences you have had in your student's learning history:
*
Why do you believe chooselife EDU Co-Op is a fit for your student at this time:
*
How has your student responded to the potential change in their education? Are they excited, frustrated, etc:
*
Tuition Payment schedule
Weekly (online Billing system)
(Late payment/pick up fees additional)
Who is your closest friend at church and why:
*
How often do you attend church and why:
*
What is one thing you have learned this past year at church that has really impacted you?
*
How often have you received D-Hall this past year and for what reasons?
How many times have you received an F on your report card this past school year and for what reason?
How many times have you been grounded or what has been the primary reason for being spanked?
In what way have you grown spiritually this year?
What person did you have the most impact on spiritually this past year and why?
Are there any concerns you have about student participation in chooselife EDU Co-Op?
*
Is there any other information that would be helpful to our management and staff?
*
Date Submitted
*
MM
DD
YYYY