Victorious Kidz Christian Academy

Date Form Completed:  ______________________

CHILD INFORMATION:

Child’s Full Name: 

Last______________________ First_____________________ Middle:_________

Date Of Birth:­­­­­­­­­­­­­­ ______________________________________________________

Social Security Number:  _______ - _______ - _______

Are there any specific needs your child has that may need to be addressed while in the care of Victorious Kidz Academy?   [  ] Yes  [  ]No

If yes, please explain:_________________________________________________
__________________________________________________________________
__________________________________________________________________

PARENT INFORMATION:

Parent(s) Name:_____________________________________________________

Address:___________________________________________________________

Telephone:  Home______________ Work_______________ Cell______________

Other contact name & number(s):_______________________________________

Best time to receive a call:_____________________________________________

Please Note:  The Pre-Enrollment form does not take the place of a complete enrollment application.  All parents will be scheduled to complete the Enrollment Packet with a Resource Coordinator prior to the date your child starts school.  All registration fees are non-refundable.

Parent Signature:_______________________________________________________________________

Parent Name Printed:___________________________________________________________________

FOR OFFICE USE ONLY

REGISTRATION PAID [   ]  AMOUNT $________  CASH [  ]  CHECK[  ]  CREDIT CARD[  ] 

CHILD(REN) ADDED TO CLASSROOM ROSTER?  [  ]YES   [  ]NO  IF YES, WHAT GRADE LEVEL:____________

Victorious Kidz Representative: ________________________________ Date:______________________