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Student Personal Information

Note: Parent/Guardian must complete this application and sign this form as indicated.

First Name

Last Name

Preferred Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Birth Date

Age

Current Grade

Gender

Male

Female

Prefer not to say

Parent/Guardian Information

First Name

Last Name

Relationship to Student

Home Phone / Cell Phone

Work Phone (If different than Home/Cell)

Emergency Contact Information

First Name

Last Name

Phone/Mobile

Authorized Pick-up List

Is there someone (other than parents or guardians) you would like to authorize to check-out/pick-up the student?

Yes

Authorized Person

Full Name	Relationship	Phone Number

eSignature of Parent or Guardian (Type Full Name)

Date

Medical Details

Is the student covered by medical/hospital insurance?

Yes

Insurance Carrier or Plan Name

Policy Number

Physician Name

Physician Phone Number

Preferred Hospital

Does the student have allergies?

Yes

Allergies: List all known allergies (e.g., peanuts, bee stings, food, medicine, etc.)

Describe Reaction and Treatment

Medicine required during Dream Academy

Dosage frequency and reason for medication

Please describe any other health related issues that the Dream Academy staff or medical personnel should know about this student when administering care

Transportation / Permissions

I give permission for my child to attend all offsite activities planned as part of the Dream Academy. I understand the academy will provide transportation.

Yes

Routine and/or Emergency Care: I hereby grant permission to the Dream Academy Staff to secure emergency treatment and/or routine medical care as needed for my child while at camp. I understand and agree to be responsible for the cost of such treatment.

Yes

Publicity: Photographs or videos taken may be used for Dream Academy marketing and publicity.

Yes

eSignature of Parent or Guardian (Type Full Name)

Date

Discipline Policy

- Verbal Warning: The student is given a warning or reminder. The staff member will explain to the student the rule that has been broken and the consequences if the behavior continues.

- Withdraw Privileges: If the behavior is repeated, the child will lose 10 minutes of play time or a fun activity. The staff member will explain to the student why he/she is not permitted to participate in the activity.

- Behavior Slip: A behavior slip will be sent home with the student if the behavior is repeated. The parent/guardian must sign the form and return it to academy the next day. The form will only be sent home if the behavior is repeated a second time.

- Final Warning: If the student continues to break the rules after warnings and the note to the parent/guardian, a conference will be arranged with the Academy Director(s) and the parent/guardian to discuss other alternatives to guide the child toward positive behavior.

- Expulsion: If after all alternatives have been exhausted and inappropriate behavior continues, the student will not be permitted to return to the Dream Academy, and any applicable fees are non-refundable.

No student will be subject to physical or corporal punishment, verbal abuse, or threats. No student or group of students will be allowed to discipline another student.

Please sign to acknowledge that you have read and understand the discipline policy.

eSignature of Parent or Guardian (Type Full Name)

Date

Program Policies

We encourage you to read each of the following policies and sign below to indicate your understanding.

Waivers/Permission
- I permit my student to participate in activities The Dream Academy conducts outside and inside the church facilities.
- Field Trips/Excursion Practicums: I permit my student to leave The Dream Academy.
- Photography/Videography: I permit The Dream Academy to use images of my student as a program participant in internal and external promotional materials. This includes any printed material, promotional videos, and The Dream Academy website. I understand that my student’s name will not be published.

Accidental Insurance
Participants are responsible for their own accidental insurance while attending The Dream Academy and all activities and field trips associated with the camp (on-site and off-site).

Emergency
In the event of an emergency and the parent cannot be contacted, Emergency Medical Staff and The Dream Academy Staff may take appropriate action in the best interest of the student.

Please sign to acknowledge that you have read and understand the program policies.

eSignature of Parent or Guardian (Type Full Name)

Date

Submit the necessary forms for enrollment

Step 1. The Enrollment Form

Student Personal Information

Parent/Guardian Information

Emergency Contact Information

Authorized Pick-up List

Medical Details

Transportation / Permissions

Discipline Policy

Program Policies

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