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Student's Name:	______________________________________________________________
Date of Birth: _________________________________________________________________
Current School/ Grade: _________________________________________________________
Parent’s / Guardian’s Name:______________________________________________________
Home Address :_______________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Phone: H_____________________ W_______________________ C ____________________
E-Mail Address:________________________________________________________________
How did you find about us?________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Special Note about the child:_______________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Current Report Card : ___________________________________________________________
Session : Spring – 2006(August 20, 2006 through December 17, 2006)

Medical / Physical Injury Agreement:

In case of any medical emergency, I, _________________________________________, the parent and/or legal guardian of the child, agree to let Basics Learning Academy personnel contact emergency room of local hospitals. I understand that Basics Learning Academy holds no responsibility whatsoever concerning my child's sickness / Injury. However, Basics Learning Academy should inform me about the situation as soon as possible.

SIGNATURE: _____________________________ DATE: ____________________