Summit Academy Enrichment Application
For AM and PM Kindergarteners
* Required
Email
*
Your email
Student Information
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Birthdate
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Parent/Guardian Information
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Parent/Guardian Phone Number
*
Your answer
Parent/Guardian Email
*
Your answer
Parent/Guardian Additional Phone Number
Your answer
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Emergency Contact Information
(Other than above parent contact)
I give permission for the following people to pick up my child from school.
#1 Emergency Contact (First Name)
*
Your answer
#1 Emergency Contact (Last Name)
*
Your answer
#1 Emergency Contact (Phone Number)
*
Your answer
#1 Emergency Contact
Additional Phone Number
Your answer
#2 Emergency Contact
*
First Name
Your answer
#2 Emergency Contact
*
Last Name
Your answer
#2 Emergency Contact
*
Phone Number
Your answer
#2 Emergency Contact
Additional Phone Number
Your answer
Additional Person who can pick up your child?
Your answer
Additional Person who can pick up your child?
Your answer
Does your child have any known allergies?
*
Yes
No
If yes, please provide emergency treatment instructions
Your answer
Does your child have any special physical or mental needs?
*
If yes, please contact the Coordinator regarding these needs.
Yes
No
Do you or a family member work for Summit Academy? If Yes, Which campus and Name of the Employee.
*
Your answer
Does this student have a sibling attending?
*
Summit Academy Preschool
Elementary
Jr. High
High School
None
Required
Class Tuition and Location
Class Times
A.M. Enrichment
8:10AM- PM Kindergarten Start time
P.M. Extend
AM Kindergarten End time-1:00PM
P.M. Enrichment
AM Kindergarten End Time - 3:00PM Monday-Thursday and 1:00 Friday
Campus
*
Bluffdale
Independence
Draper
Please select days needed for PM Extend till 1:00PM (PM Kindergartners)
*
Monday
Tuesday
Wednesday
Thursday
Friday
N/A
Required
Please select days needed for PM Enrichment, Monday-Thursday3:00PM, Friday 1:00PM
*
Monday
Tuesday
Wednesday
Thursday
Friday
N/A
Required
Where did you hear about Summit Academy Preschool/Enrichment?
Your answer
Final Step to complete your Enrichment application
1. Review and sign the Consent/Waiver & Agreements forms:
https://drive.google.com/file/d/1uUfFmlZOpAx6b2znyVMNmy6R7TtG8huj/view?usp=sharing
2. Copy of Students Immunization Record or Exemption Form emailed
preschool@2summit.org
or faxed to 801-572-9875.
3. $50 Registration fee submitted online at
https://secureinstantpayments.com/sip/?ID=16007
4. Review and Sign Summit Academy Media consent form:
https://4.files.edl.io/2194/12/07/20/212847-a1bbe5a6-6053-4468-b430-a75151db56b8.pdf
Forms can also be submitted along with a $50.00 registration fee to the elementary office at:
Summit Academy Draper Campus,
1285 East 13200 South, Draper, UT 84020
OR
Summit Academy Independence Campus,
15327 South Noell Nelson Dr, Bluffdale, UT 84065
OR
Summit Academy Bluffdale Campus,
1940 West 14400 South, Bluffdale ,UT 84065
ENROLLMENT NOT COMPLETE UNTIL ALL ABOVE ITEMS ARE RECEIVED.
* Tuition is due by the first (1st) of each month; a late fee of $5.00 per day is then applied to your account after the fifth (5th). In the event that any balance is not paid as agreed, the undersigned agrees to pay a collection fee equal to 40% of the unpaid balance. In the event of a collection action or lawsuit is commenced, the undersigned further agrees to pay cost, services charges, court cost and reasonable attorney's fees.
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