2018-2019 Voluntary Pre-K Online Enrollment
Excell Academy is an equal opportunity public charter school. No child will be denied enrollment on the basis of race, ethnicity, social-economic status, mental or physical challenges, religion, etc.
Your child must be Four years old by September 1, 2018 to attend the Voluntary Pre K Program at Excell Academy.
Child's Last Name *
Your answer
Child's First Name *
Your answer
Middle Initial
Your answer
Date of Birth *
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Please select one of the following progrmas *
Last School/Daycare attended *
Name and Phone Number
Your answer
Public School District in which you live in *
Your answer
Language spoken at home *
Your answer
How did you hear about Excell Academy? *
Your answer
Family Situation *
Who does your Child Live with?
Required
Student's Street Address *
Your answer
Apt Number
Your answer
City, State *
Your answer
Zip Code *
Your answer
Have you recently moved to our district within the past 36 months for temporary or seasonal agriculture or fishing work? *
Biological Mother's Last Name *
Your answer
Biological Mother's First Name *
Your answer
Are you the child's biological mother? *
Mother's Daytime Phone Number *
Your answer
Type of Daytime Phone Number *
Mother's Street Address *
Your answer
Apt #
Your answer
City, State *
Your answer
Zip Code *
Your answer
Mother's Place of Employment *
Your answer
Mother's Place of Employment Phone Number *
Your answer
Mother's Email Address
Your answer
Biological Father's Last Name *
Your answer
Biological Father's First Name *
Your answer
Father's Daytime Phone Number *
Your answer
Type of Primary Phone Number *
Required
Father's Street Address *
Your answer
Apt #
Your answer
City, State *
Your answer
Zip Code *
Your answer
Father's Place of Employment *
Your answer
Father's Place of Employment Phone Number *
Your answer
Father's E-mail Address
Your answer
Legal Guardian First Name (IF OTHER THAN BIOLOGICAL PARENTS)
Your answer
Legal Guardian Last Name (IF OTHER THAN BIOLOGICAL PARENTS)
Your answer
Legal Guardian Daytime Phone
Your answer
Legal Guardian Street Address
Your answer
Apt #
Your answer
City, State
Your answer
Zip Code
Your answer
Federal Ethnicity and Race
Is the student Hispanic or Latino *
Race *
Select all that apply
Ethnicity *
Select one
Emergency Contacts
Emergency Contact Name #1 *
(other than parent(s) or a doctor)
Your answer
Emergency Contact #1 Relationship *
(other than parent(s) or a doctor)
Required
Emergency Contact #1 Telephone Number *
Your answer
Emergency Contact #1 Street Address *
Your answer
Apt #
Your answer
City, State *
Your answer
Zip Code *
Your answer
Emergency Contact Name #2 *
(other than parent(s) or a doctor)
Your answer
Emergency Contact #2 Relationship *
(other than parent(s) or a doctor)
Required
Emergency Contact #2 Telephone Number *
Your answer
Emergency Contact #2 Street Address *
Your answer
Apt #
Your answer
City, State *
Your answer
Zip Code *
Your answer
Emergency Contact Name #3 *
(other than parent(s) or a doctor)
Your answer
Emergency Contact #3 Relationship *
(other than parent(s) or a doctor)
Required
Emergency Contact #3 Telephone Number *
Your answer
Emergency Contact #3 Street Address *
Your answer
Apt #
Your answer
City, State *
Your answer
Zip Code *
Your answer
Person(s) Authorized to Pick up Child from School *
Please note that it always required for a parent/legal guardian to notify Excell Academy when an authorized person will be coming to pick up your child. Students will not be released unless a phone call has been received.
Your answer
By submitting my electronic signature, I hereby agree that I must call Excell Academy to notify them that someone other than myself will be picking up my child, my child will not be released to an authorized person until I have notified Excell Academy, and proper identification must be provided by the authorized person at the time of pick up. *
Your answer
Person(s) NOT Authorized to Pick up Child from School
Excell Academy does not release students to ant person without parent consent and notification. Please list name of any person(s) who are unauthorized to pick up your child from school. A court order must be provided if a biological parent is listed.
Your answer
Home Environment
Parents are *
Names and ages of Siblings *
Name, DOB, School Attending
Your answer
Other adults in the household *
Name, Relationship
Your answer
Social/Emotional Development
Previous Educational Experiences *
Your answer
Do you consider your child to be *
Does your child have playmates? If so, what ages/gender? *
Your answer
Check the word(s) that describe your child *
Required
What makes your child frustrated or upset? *
Your answer
Describe discipline used at home *
Your answer
Describe any fears your child may have and how you have dealt with them *
Your answer
What are your child's favorite play activities? *
Your answer
Describe any special interest of your child *
Your answer
Activities that your child is cautious about *
Your answer
Child is *
Other comments about your child's developments
Your answer
Behavior: *
Students are expected to maintain good behavior at all times during the Kindergarten Readiness Program. If the behavior is not appropriate, students will be given two warnings along with a conference with parents. If after the warnings the behavior does not improve the child(ren) may be asked to leave the program. Excell Academy will not tolerate inappropriate/misbehavior in the Kindergarten Readiness program. By signing the following electronically, I agree to comply with the above behavior policy at Excell Academy for Higher Learning.
Your answer
Consent for NON Prescription Medicine *
I hereby give Excell Academy permission to apply any of the following external preparations that are checked, in accordance with directions for use on the appropriate container.
Required
Is your child on an IEP (Individualized Education Plan) *
Please select any special development needs your child may have that we should be aware of *
Required
Students must be completely toilet trained to attend the program
Is your child bladder trained? *
Is your child bowel trained? *
Any concerns in this area? *
Your answer
Does your child take a regular nap? If so, what time? *
Your answer
Is there anything unusual about your child's appetite? *
Your answer
Favorite Foods *
Your answer
Food Dislikes *
Your answer
Any usual eating habits *
Your answer
Food allergies *
Your answer
Your Expectations
What do you want most out of your child's experience at Excell Academy? *
Your answer
Areas of Development you want to see emphasized *
Your answer
Any other information your consider important for Excell Academy to know?
Your answer
Submitting your Application
By signing your electronic signature below, you are enrolling your child into Excell Academy. If you have selected to attend the extended day program, fees must be paid in order to reserve enrollment. *
Your answer
Today's Date *
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