SYNERGY PREP
Registration Application
Please fill out this form and submit to register your student.
We will also need the following:
*A Valid Birth Certificate
*Current Immunization Records
*Current Eye, Ear, & Dental Form
*Copy of Student Records (academic & discpline)
Personal Information
Today's Date
MM
/
DD
/
YYYY
Synergy Prep Program
Please select
FLEXD-U
SPEED-U
THRIVE-U
Please select
Student Full Legal Name
Name Student Prefers To Be Called
Birthday
MM
/
DD
/
YYYY
Gender
Please select
Female
Male
Please select
Age
Grade Level To Begin at Skipstone
Address
Student Cell Phone Number
(or main parent / guardian if student does not have a cell phone)
Student Email Address
(or main parent / guardian if student does not have an email address)
T-shirt Size
Please select
Youth X-Small
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult 2X-Large
Adult 3X-Large
Please select
Family Information
#1 Parent / Guardian Name
#1 Parent / Guardian
Place of Business
#1 Parent / Guardian
Relation to Student
#1 Parent / Guardian
Work Phone Number
#1 Parent / Guardian
Cell Phone Number
#1 Parent / Guardian
Email Address
#2 Parent / Guardian Name
#2 Parent / Guardian
Place of Business
#2 Parent / Guardian
Relation to Student
#2 Parent / Guardian
Work Phone number
Parent / Guardian
Cell Phone Number
#2 Parent / Guardian
Email Address
Who does the student live with?
Who will be responsible for tuition for student?
Siblings & Ages
Emergency Contact First / Last name
(other than Primary Parents / Guardians listed above)
Emergency Contact Phone number
(other than Primary Parents / Guardians listed above)
Education Information
School Last Attended
Address of Previous School
Has student been suspended or expelled from school for any reason?
Please select
No
Suspended
Expelled
Please select
If yes, please explain
Is student on IEP, EIP or 504 Plan at current school?
Please select
No
IEP
EIP
504 Plan
Please select
Medical Information
Please list any and all allergies/medical conditions for your student (if none, please write "none").
Please list any physical, educational, emotional challenges that staff would need to be aware of so that we can best care for and educate student (if none, please write "none").
Please list any medications that the student receives regularly and list the condition for which the medication is taken (if none, please write "none").
Consent for Medical Treatment: It is my understanding that Skipstone Academy will notify me immediately in case of any emergency or serious illness such as would require a physician's attention. In the event that I cannot be reached, the physician/medical facility has my permission to treat my child. (Please sign below.)
Medical Treatment Release Signature
Clear
I hereby grant permission to Skipstone Academy to use photographs and/or video of my child in Skipstone publications such as the Skipstone Website, Facebook, Instagram and the Skipstone Academy Yearbook. (Please sign below.)
Permission To Post Pictures / Videos Release Signature
Clear
SUBMIT FORM
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