Student Enrollment Form Student Name * First Name Last Name Preferred Email for Invoices * Phone (###) ### #### Student Birthday MM DD YYYY Student Grade * Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Address * Address 1 Address 2 City State/Province Zip/Postal Code Country School * Name of First Contact * First Name Last Name Relation to Student * Email * Phone * (###) ### #### Name of Second Contact * First Name Last Name Relation to Student * Email * Phone * (###) ### #### Has your child had a psychoeducational assessment? * Yes No Date of Assessment MM DD YYYY Provider Identification/Diagnosis Does your child have an Individual Education Plan? * Yes No Does your child receive accommodations or curriculum modifications at school? * Yes No Please tell us about the modifications/accommodations your child receives at school? Does your child have any allergies? * Does your child carry an EpiPen? * Yes No Additional medical information Current medications Does your child have permission to leave Appletree Learning Centre on their own after the session? * Yes No Appletree would like to ask for your consent to occasionally photograph or record your child hard at work during their session at Appletree. Photos and/or videos will only be taken by Appletree's administrative team or your child's teacher, and will only be used on our Social Media platforms (i.e., Instagram, Facebook and LinkedIn) and website. We would like to share pictures of your children working during their session, participating in Appletree activities, and presenting their excellent written work. Appletree takes your privacy and that of your child very seriously. We will not distribute any information about you or your child without your expressed, written consent. No, I do not consent to having Appletree photograph or record my child during their session. Yes, I consent to having Appletree photograph or record my child during their session. Yes, I consent to having Appletree photograph or record my child as long as there isn't anything in the picture or recording that identifies who my child is. Thank you!
