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LIFE CHRISTIAN ACADEMY

 

REGISTRATION APPLICATION

 

Date______________

 

STUDENT FULL NAME ___________________________________________

 

Address ______________________________________________________

             City _____________________ State_____________ Zip ________

 

Phone _________________________ Social Security Number ___________

 

Age ______________ Birthdate _______________________

Grade _____________ Male/Female _______________ Race ___________

 

Mother’s Name ________________________________________________

Address ______________________________________________________

Employer __________________________ Phone _____________________

Social Security Number _____________________

Phone ______________________ Cellular Phone _____________________

 

Father’s Name _________________________________________________

Address ______________________________________________________

Employer __________________________ Phone _____________________

Social Security Number _____________________

Phone ______________________ Cellular Phone _____________________

 

Person to contact in case of Emergency:

_____________________________________ Phone __________________

_____________________________________ Phone __________________

 

 

Medical Problems : ____________________________________________

____________________________________________________________

____________________________________________________________

 

Medication Taking : ____________________________________________

Allergies : ____________________________________________________

Medication for Allergies : ________________________________________

Family Physician : ______________________________________________

Address : _____________________________ Phone : _________________

 

Signed consent for treatment in case of emergency :

_____________________________________________________________

 

Insurance Co. _________________________________________________

Policy # __________________________ Cert. # _____________________

 

Attach copies of immunization records

 

IMMUNIZATION REQUIREMENTS

2008-2009

 

 

TB

 

DPT                  4 shots with 1 after the 4th birthday

 

POLIO         3 shots required, 4 preferred with 1 after the 4th birthday

 

MMR                   2 shots with 1st one on or after 1st birthday

 

HEPATITIS B

                  3 shots     If born 9-2-88 to 9-2-92 must have 3 shots by

                  age 12

 

CHICKEN POX

                  Varicella   If born 9-2-88 to 9-2-94 must have 1 shot by

                  Age 12,    must have 2 shots age 13 or above

 

10 year          BOOSTER

 

 

Health Dept gives shots weekly 12:30 to 4:00

         No TB on Thursday

Phone # 237-2620

 


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