BCA/WPS 2017-18 Registration Form
Thank you for taking the time to submit this important information regarding your student.

This form should take 15-30 minutes to complete and needs to be finished in one sitting so please plan accordingly. Note: If you exit this form prior to submission all data entered will be lost.

Email address *
Student Information
Student's Legal First Name *
Your answer
Student's Legal Last Name *
Your answer
Student's Preferred Name (Optional)
Your answer
Student's Gender *
Student's Date of Birth *
MM
/
DD
/
YYYY
Student Preferred Address - Street *
Your answer
Student Preferred Address - City *
Your answer
Student Preferred Address - State *
Student Preferred Address - Zip *
Your answer
Ethnic Background *
Student's Grade (Fall 2017) *
What is the first year this student entered BCA/WPS? *
Does this student have any siblings who CURRENTLY attend BCA/WPS? *
If yes, please list the name and grade of any sibling who attends BCA/WPS
Your answer
Please list the name and grade of any sibling who DOES NOT attend BCA/WPS
Your answer
Parent/Guardian Information
This information will only be used for internal school communication. It is not to be used for any solicitation. Email and phone numbers will be published in the BCA/WPS Student Directory.
Parent/Guardian 1 Name - Primary Contact (To be published in Student Directory) *
Your answer
Parent/Guardian 1 Preferred Salutation *
Parent/Guardian 1 Relationship to Child *
Parent/Guardian 1 Phone # (To be published in Student Directory) *
Your answer
Parent/Guardian 1 Alternate Phone #
Your answer
Parent/Guardian 1 Email (To be published in Student Directory) *
Your answer
Parent/Guardian 1 Employer *
Your answer
Parent/Guardian 1 Profession *
Your answer
Parent/Guardian 2 Name (To be published in Student Directory) *
Your answer
Parent/Guardian 2 Preferred Salutation *
Parent/Guardian 2 Relationship to Child *
Parent/Guardian 2 Phone # (To be published in Student Directory) *
Your answer
Parent/Guardian 2 Alternate Phone #
Your answer
Parent/Guardian 2 Email (To be published in Student Directory) *
Your answer
Parent/Guardian 2 Employer *
Your answer
Parent/Guardian 2 Profession *
Your answer
(Optional) Any details of parenting arrangements you'd like to share
Your answer
Emergency Contact Information
Emergency Contact Person 1 (If parents not available) *
Your answer
Emergency Contact Person 1's Relationship to Student *
Your answer
Emergency Contact Person 1's Phone # *
Your answer
Emergency Contact Person 2 (If parents not available)
Your answer
Emergency Contact Person 2's Relationship to Student
Your answer
Emergency Contact Person 2's Phone #
Your answer
Out of State Emergency Contact Person (Optional)
Your answer
Out of State Emergency Contact Person's Relationship to Student (Optional)
Your answer
Out of State Emergency Contact Person Phone # (Optional)
Your answer
Authorized Pickup Person(s)
Both Parent/Guardians will automatically be setup as being authorized to pickup this student from the school.

If you would like to, you can specify up to two additional people below to be authorized to pick up this student.

Additional Authorized Pickup Person 1
Your answer
Relation of Authorized Pickup Person 1 to Student
Your answer
Additional Authorized Pickup Person 2
Your answer
Relation of Authorized Pickup Person 2 to Student
Your answer
Additional Authorized Pickup Person 3
Your answer
Relation of Authorized Pickup Person 3 to Student
Your answer
Photo/Video Release Authorization
By completing this enrollment form you are granting BCA/WPS permission to use your child's likeness in a photograph, video, and/or other digital media in any and all of its publications, including web-based publications, without payment or other consideration.

If you want to opt out, use this link to complete the Opt Out form.

https://goo.gl/forms/VLkQkj6fIQQ62vC23

Commercial Transportation Release Authorization
By answering yes to this question, you are granting BCA/WPS permission to use commercial transportation/school-provided transportation to transport your child for field trips and/or other events, when needed.
Please select below. *
Student Medical Information
Student's Doctor's Name *
Your answer
Student's Doctor's Phone # *
Your answer
Date of Last Physical Exam *
Your answer
Student's Dentist's Name *
Your answer
Student's Dentist's Phone # *
Your answer
Student's Medical Insurance Provider Name *
Your answer
Student's Medical Insurance Policy # *
Your answer
Does your child have any allergies? *
List allergies below (Skip this question if no allergies)
Your answer
Dietary Information
Does your child have any food restrictions? *
List food restrictions below (Skip this question if no food restrictions)
Your answer
Please select the desired menu choice to assist Admin. staff ONLY IF last minute ordering becomes necessary (Optional)
Please select the desired milk/no milk choice to assist Admin. staff ONLY IF last minute ordering becomes necessary (Optional)
Student Other Information
Does your child have any special needs? *
List special needs below (Skip this question if no special needs)
Your answer
BCA After-Care: Important note below
The following questions were created to support the beginning of year planning for our After-Care staffing. IMPORTANT:
Please know that our BCA After-Care will continue to be offered on an 'as-needed' basis with no prior registration necessary.
Do you intend for your child to attend BCA's After-Care on a regular basis? *
If yes, please identify the applicable days below
Parent Association (PA)
Please select PA volunteer choice. (BCA parents only, WPS parents please select Not-Applicable) *
A copy of your responses will be emailed to the address you provided.
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