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Carroll Academy
  STUDENT INFORMATION  
 

New Student Returning student last attended session/year:
New family

If enrolling more than one student, please attach separate sheet with all necessary information.

 
Student's last name:
 
First name:
 
Middle name :
 
Age:
Date of birth:
 
Gender:
Male Female
 
Social Security number:
 
c/o:
 
Address:
 
City:
 
State:
 
ZIP:
 
Name of school:
 
School_City
 
E-mail:
 
Grade entering
 
School programs involved in now?
 
Carroll Academy Teacher (if current student):
 
Previous experience (if new to the program):
 
Where did you hear about us?
PARENT INFORMATION  
 
Mother's name
 
Father's name
 
Address (if different from above)
 
Home phone:
 
Parent/Guardian cell:
 
Mother business phone:
 
Father business phone:
 
Name of participant's physician:
 
Physician phone number:
SPECIAL NEEDS  
 
Allergies:
Yes No, If yes, please identify the type of allergy:
 
Treatment/care required:
 
Other? Please identify with specificity:
 

I have read and understand the policies.
I have completed and signed the release, waiver and consent form.
Check enclosed for $
Please charge $

Visa MasterCard American Express


Card number: Expiration date:

Signature: Date:

  New lesson students: Please include a listing of all available times for lessons and a description of the student, detailing special needs and interests.
Returning students: Communicate need for change of times directly with your teacher.
     
  Session attending: Fall Spring Summer
 
Title of course:
 
Location:
 
Class fee:
 
Additional information/comments:
     
 
Title of course:
 
Location:
 
Class fee:
 
Additional information/comments:
     
 
Title of course:
 
Location:
 
Class fee:
 
Additional information/comments:
     
 
Title of course:
 
Location:
 
Class fee:
 
Additional information/comments:
     
  Please mail check, this application, a completed release, waiver, and consent form, as soon as possible to: Carroll University Academy, 100 N. East Ave., Waukesha, WI 53186  
     
 
For Office Use Only:
Date rec'd:
    Amount enclosed:
    Cash Check VISA MasterCard
    Input into: Blue Book Computer
    Date deposited:
 
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