Covenant Churches of East Texas - CovAcademy Registration

Student Information:

First Name

Last Name

Address 1

Address 2

Country

City

State

Zip/Postal Code

Grade

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

CovAcademy Registration Form

Student Information:

Parent/Guardian Information:

Emergency Contact Information:

Additional Information

Digital Signature

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Contact Info

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