Covenant Churches of East Texas
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CovAcademy Registration Form
Student Information:
First Name
Last Name
Address 1
Address 2
Country
City
State
Zip/Postal Code
Grade
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
DOB
Sex
Male
Female
Does Student Have any Allergies, Medical Conditions, or use an EpiPen or Inhaler?
Yes
No
If Yes, Please List
Does Student Have any Educational Considerations we Need to be Aware of as Tutors Work with Them? (Dyslexia, Oral Accommodations, Etc.)
Yes
No
If Yes, Please List
Parent/Guardian Information:
First Name
Last Name
Address if Different from Student
Home Phone Number
Cell Phone Number
Email
Place of Employment
Work Phone Number
Emergency Contact Information:
First Name
Last Name
Address if Different from Student
Home Phone Number
Cell Phone Number
Additional Information
Do You Give Permission for CovAcademy to Post Pictures or Classroom Activities, Including Your Child on the Church Website, App or Facebook?
Yes
No
How Would You Like to Pay our Attendance Fee? ($10.00 per day for child, plus $5.00 per day for each sibling)
Weekly (Every Monday)
Monthly
Semester
Who Will be the Main Person Picking up Your Student Most Days at Noon
Please List all Persons Available to Pick up Your Child From CovAcademy
Digital Signature
First Name
Last Name
Date Signed
Register