Concordia Creative Learning Academy

REGISTRATION FORM
Please print the form to fill out and return to CCLA

Child's Name ___________________________________ Sex _____ Date of Birth______________ Grade ______

Address ____________________________________ City ________________ State ____ Zip _____________

Social Security Number __________________________ Home Phone ___________________________

Previous School________________________ Address: _____________________ Phone: _______________

Child lives with: ____ Both Parents   ____ Mother   ____ Father   ____ Guardian

Parent/Guardian Name________________________________________ Relationship ____________________

Home Phone __________________ Work Phone __________________ Cell/Pager __________________

Parent/Guardian Name ________________________________________ Relationship ____________________

Home Phone __________________ Work Phone __________________ Cell/Pager __________________

List sisters or brothers at CCLA:

______________________________ Grade _____

______________________________ Grade _____

Racial/Ethnic Group

____ Native American/Alaskan ____ Asian* ____ Hispanic ____ African American ____ Caucasian
*If Asian, please select one ____ Pacific Islander ____ Hmong ____ Vietnamese ____ Cambodian ____ Laotian ____ Other

Home Language, if not English ___________________________________

Have you moved into this school district within the last 36 months for temporary or seasonal agricultural or fishing work? ____ yes ____ no

Has your child ever received an educational assessment (IEP or Section 504 Plan)? ____ yes ____ no

Please list any other special medical or educational needs or accommodations that we should be aware of:

_________________________________________________________________________________

_________________________________________________________________________________

Physician's Name______________________ Phone _________________ Hospital _______________________

EMERGENCY CONTACTS:

This if very important! If your child becomes ill at school or if school closes for an emergency, we must be able to contact someone who can care for your child. This must be someone other than listed above.

Name ____________________________ Relationship______________ Daytime phone _______________________

Name ____________________________ Relationship______________ Daytime phone _______________________

Name ____________________________ Relationship______________ Daytime phone _______________________

List anyone NOT permitted to pick your child up from school:

Name ____________________________ Relationship ________ Notes_________________________________