Summit Academy Enrichment Application
For AM and PM Kindergarteners
Email *
Student Information
Child's First Name *
Child's Last Name *
Child's Birthdate *
Gender *
Parent/Guardian Information
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent/Guardian Phone Number *
Parent/Guardian Email *
Parent/Guardian Additional Phone Number
Street Address *
City *
Zip Code *
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) *
#1 Emergency Contact (Last Name) *
#1 Emergency Contact (Phone Number) *
#1 Emergency Contact
Additional Phone Number
#2 Emergency Contact *
First Name
#2 Emergency Contact *
Last Name
#2 Emergency Contact *
Phone Number
#2 Emergency Contact
Additional Phone Number
Additional Person who can pick up your child?
Additional Person who can pick up your child?
Does your child have any known allergies? *
If yes, please provide emergency treatment instructions
Does your child have any special physical or mental needs? *
If yes, please contact the Coordinator regarding these needs.
Do you or a family member work for Summit Academy? If Yes, Which campus and Name of the Employee. *
Does this student have a sibling attending? *
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 *
Please select days needed for PM Extend till 1:00PM (PM Kindergartners) *
Please select days needed for PM Enrichment, Monday-Thursday3:00PM, Friday 1:00PM *
Where did you hear about Summit Academy Preschool/Enrichment?
Final Step to complete your Enrichment application
1. Review and sign the Consent/Waiver & Agreements forms:

2. Copy of Students Immunization Record or Exemption Form emailed or faxed to 801-572-9875.

3. $50 Registration fee submitted online at

4. Review and Sign Summit Academy Media consent form:

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
Summit Academy Independence Campus,
15327 South Noell Nelson Dr, Bluffdale, UT 84065
Summit Academy Bluffdale Campus,
1940 West 14400 South, Bluffdale ,UT 84065

* 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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