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KC Tech Academy Enrollment Form 2021/22
Name:
Date of Birth:
Gender:
Student Phone Number:
Address :
Address 2:
City:
State:
Zip Code:
Email:
Current School:
2021-2022 Grade:
Do you have any medical condition that may impact your ability to participate in this program?
No
Yes
If yes, what is your medical condition?
What is your mode of transportation to training site(s):
Personal Car
School Provided Transportation
Ride w/ another student
Public Transportation
Other
If other, what mode of transportation?
Parent/Guardian Information
Parent Name:
Relationship to Student:
Primary Phone Number:
Primary Phone Number Type:
Work
Home
Cell
Secondary Phone Number:
Secondary Phone Number Type:
Work
Home
Cell
Parent/Guardian Email:
Student Emergency Information
In case of emergency, please contact if parent/guardian cannot be reached:
Name:
Relationship to Student:
Emergency Phone Number:
Emergency Alternative Number:
In the event of a medical emergency, an effort will be made to contact the parent/guardian as soon as possible. If communicate cannot be made, you hereby grant permission for your son/daughter to receive the necessary medical treatment including ambulance services, anesthetic, blood transfusion or other, as considered necessary. I understand, medical expenses will be the responsibility of student or parent/guardian.
I do
not
authorize medical treatment including ambulance services for my child without my direct consent, in the case, myself or emergency contact cannot be reached.
Name of Family Physician:
Physician Phone Number: :
Insurance Company:
Insurance Phone Number: :
Policy Number:
Group Number
Consent and Agreement Signatures
Signature of Parent(s)/Guardian(s):
Date:
Signature of Student:
Date:
Field Trips K-12 Students only:
I understand that my student will attend field trips to local manufacturing companies in the KC area. I give permission for my child to attend KC Tech Academy sponsored events, activities, and field trips off site during the school day while attending KC Tech Academy. I also understand Liberty School District may provide transportation to these locations for all students at KC Tech Academy OR students are allowed to drive their own vehicle.
Submit Your Form
