Msa Application

Application/Contract
1. Name Child/ren:
______________________________________________________________________________
2. Age(s): _________________________
3. DOB: ___________________________________
4. Name of Parents/Guardians
______________________________________________________________________________
5. Address:
_____________________________________________________________________________________
_____________________________________________________________________________________
6. Place of Employment and phone#:
______________________________________________________________________________
______________________________________________________________________________
7. Name of Doctor and Phone #:

______________________________________________________________________________
8. Name of Insurance Company and Policy number:
_____________________________________________________________________________________
9. Emergency Hospital of Choice:

______________________________________________________________________________
10. Childs Allergies and Medications:
__________________________________________________________________________________
__________________________________________________________________________________
11. Emergency Contacts

1. Name, Relationship, Address, Phone:
___________________________________________________________________________
___________________________________________________________________________
2. ___________________________________________________________________________
___________________________________________________________________________
3. ___________________________________________________________________________
___________________________________________________________________________
12. Please list all people authorized to pick up your child/ren:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
13. Previous School/daycare and Phone#:

______________________________________________________________________________
______________________________________________________________________________
14. Transportation Authorization:

On occasion I will take the children for daily outings or field trips, the means of transportation
being my privately owned vehicle. Please fill out and sign below, this gives your child permission
to join on the outings.
I __________________________ give MSA Home Education permission to transport my
child/ren on daily outings and field trips.
Initial _________ Date ______________
15. Picture Authorization:

There are times when your child/rens picture may be taken during events, or for advertising
purposes such as flyers, brochures, or the school website as long as it is first authorized by the
parent. Please fill out and sign below, this gives permission for your child to be featured in
publications and photographed.
I _____________________________ give/do not give MSA Home Education permission to take
my child/rens picture for school purposes. Initial _________ Date______________
16. Anything else I may need to know about your child. (ex. Special interests, hobbies, habits such as
thumb sucking, nail biting ect, potty training needs, medical needs or diagnosed issues and
favorite things)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
17. My childs hours will be _________ to ___________ (hours)
__________________________________________________________(days)
18. I agree to pay ___________________ per week for my child.
19. Acceptance of Terms and Signatures:
I have read and agree to comply with all the provisions and rules outlined in the Parent
Handbook. I understand that this is a legal and binding contract and I have read everything
carefully.
Parent Signature __________________________________________________________________
Date __________________________________
Directors Signature ________________________________________________________________
Date ___________________________________

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Application/Contract

6. Place of Employment and phone#:

7. Name of Doctor and Phone #:

8. Name of Insurance Company and Policy number:

9. Emergency Hospital of Choice:

11. Emergency Contacts

12. Please list all people authorized to pick up your child/ren:

13. Previous School/daycare and Phone#:

14. Transportation Authorization:

15. Picture Authorization:

Parent Signature __________________________________________________________________

Directors Signature ________________________________________________________________

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