Summer Health/Emergency Form "*" indicates required fields Step 1 of 4 - Student Information 0% NameThis field is for validation purposes and should be left unchanged.Student InformationName* First Last Birthdate* Month Day Year Grade in September 2026*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeGender* Male Female Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Lives With* Both Parents Mother Father Other Other Has this child ever repeated a grade?* Yes No Please briefly explain any "Yes" answersHas this child ever been dismissed, suspended, or expelled?* Yes No Please briefly explain any "Yes" answersHas this child ever been recommended for, or referred to, any Resource, ESL, or Special Education?* Yes No Please briefly explain any "Yes" answersHas this child ever been diagnosed with any behavioral concerns?* Yes No Please briefly explain any "Yes" answersDoes this child have any physical limitations or handicaps?* Yes No Please briefly explain any "Yes" answersName of Child's Doctor:*Physician's Phone #Insurance:Insurance ID #:Student HealthPlease select any diagnosed health concerns for this chid. Allergy Asthma Diabetes Epilepsy/Seizures Fainting Spells Vision Problems Hearing Problem Heart Condition Migraine Headaches Please briefly explain any diagnosed health concerns.Allergies (specify type)Medications (specify any taken)Significant Medical ProblemsMother/Guardian* First Last Home Address* Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Enter Email Confirm Email Mobile Phone*Home PhoneWork PhoneFather/Guardian First Last Home Address Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Enter Email Confirm Email Mobile PhoneHome PhoneWork PhoneCustody AgreementsCustody*Do you have any current custody agreements we should be aware of? Yes No Description*Please briefly describe the agreement. Any restrictions must be accompanied by a copy of the current court order.Current Court OrderPlease upload a copy of the current court order.Max. file size: 32 MB. In the event that I am unable to pick up my child, he or she may be released to any of the persons listed below:Name* First Last Relationship to Child*Contact Information Same as previous Street Address City ZIP Code Mobile Phone*Other PhoneName* First Last Relationship to Child*Contact Information Same as previous Street Address City ZIP Code Mobile Phone*Other PhoneName First Last Relationship to ChildContact Information Same as previous Street Address City ZIP Code Mobile PhoneOther Phone Authorization AgreementPlease read through the Admission Agreement and check the box below. Please note: Jubilee Christian School is known hereafter as "JCS." JCS reserves the right to change or modify academic, administrative, and financial policies as necessary, while recognizing its obligation to give parents adequate notice of any changes.Medical Authorization* I have read, understand, and agree to the above Parent/Legal Guardian Signature* Application ReviewPlease take a moment to review your Health/Emergency Form in full.{all_fields}Post Custom Field
