Author: gregp

MARLTON CHRISTIAN ACADEMY
Elementary Office 856-988-8503
625 E. Main St., Marlton, NJ, 08053
www.mcaschools.org

Kindergarten/Elementary School Registration
Child’s Name: _______________________________________________________________________________
Grade: _______ Year: __________ Today’s Date: ____________ Nickname:____________________________
Address: _____________________________________ Town:___________________ Zip: ________________
Phone: ( ) _______________________ Date of Birth: Sex:
E-mail address: _______________________________ E-mail address: ________________________________
My Child’s Family:
Father or Guardian (circle one)
Name: ____________________________________________ Cell Phone: ( ) ________________________
License #: _________________________________________
Business Address: ________________________________ ______ ______ ___________________ (name of organization) (street) (city, state)
Occupation: _____________________________________________ Bus. Phone: ________________________
Mother or Guardian (circle one)
Name: ____________________________________________ Cell Phone: ( ) ________________________
License #: ____
Business Address: ________
(name of organization) (street) (city, state)
Occupation: _____________________________________________ Bus. Phone: ________________________
Parents are: Living together: ______________ Living apart: _ Divorced:
Date of divorce or separation: Additional home phone: _________
Others living in the child’s home:
Name: Age: Relationship:
Name: Age: Relationship:
Name: Age: Relationship:
Family Religious History:
Name of church you attend: _____________
Denomination: Years attended: _____________
Pastors Name:
Referred to MCAE by
(Please see reverse side)

Scholastic Information:
Name of previous school: Last grade completed:
Address of school: _____________
Has your child ever had disciplinary difficulties? No: Yes:
Explain: _____________
Has your child ever failed in school? No: Yes:
Explain: _____________
I. E.P. History: ___________________
Child’s Health History:
Pediatrician: Phone:
Choice of hospital: _________________
Has your child had any serious illness, physical handicap, medical conditions, allergies,
Diet or physical restrictions? Please list & explain:_________________________________________________________
____________
Does your child take any medications on a regular basis?
Name of Medication: Total daily dosage:
Name of Medication: Total daily dosage:
Was your child born prematurely: _____ How may weeks early: _ Birth weight: ______
Medical Release: By signing this form, you release Marlton Christian Academy, Marlton Assembly of God Church and the employees of those organizations of any liability in the event of an accident or injury while your child is attending classes or other activities sponsored by Marlton Christian Academy.
Emergency Contacts: Every attempt will be made to contact the parents in case of an emergency. All students must have a place available to go in the event that they are ill and must leave the school. If neither parent can be reached, contact:
Name: Relationship:
Address: _________________
Home Phone: Bus Phone:
Name: Relationship:
Address: ______________
Home Phone: Bus Phone:
Release Form: The following people have permission to pick up my child. Please contact the main office to make special arrangements beforehand by WRITTEN PERMISSION or PHONE. Picture identification is required.
By law copies of custody papers, legal guardian documents, and restraining orders must be submitted to school office.
Signature of parent or legal guardian: ________________________________________ Date: ______________