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THE ACADEMY OF EXCELLENCE

AOE REGISTRATRION FORM

Registration Form

Registration Cost Is $75

Birth Date

Sex

Male

Female

Date Of Enrollment

Full Name - Last - First - Middle - Nickname

Child's Physical Address

Primary Hours of Care of the week in care:

Mother's Full Name

Address

Home Phone

Employer

Address

Work Phone

Cell Phone

Current Grade Level

Child Lives With

Father's Full Name

Address

Home Phone

Employer

Address

Work Phone

Cell Phone

Custudy

Mother

Father

Both

Other

Medical Information

I hereby grant permission for the staff of this facility to contact the following medical personnel to obtain emergency medical care if warranted.

Doctor

Address

Phone

Doctor

Address

Phone

Dentist

Address

Phone

Hospital Preference

Please list allergies, special medical or dietary needs or other areas of concern:

Emergency care plan (if applicable):

Emergency Contacts

Child will be released only to the custodial parent or legal guardian and the persons listed below.

The following people will also be contacted and are authorized to remove the child from the facility

in case of illness accident or emergency. If for some reason the custodial parent or legal guardian

cannot be reached:

Name

Address

Work#

Phone#

Name

Address

Work#

Phone#

Name

Address

Work#

Phone#

Prior School History

Thank You!

Globally Accredited by:

Tel: (904) 779- 0177

Fax: (904) 779 - 0250

Email: admin@theaoejax.com

Address

8601 Youngerman Ct.

Jacksonville, FL 32244

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