Student Name

Birth Date

Gender

Address

City

State

Zip

Current School

Current Grade

Medical issues

Medical needs

Medication allergies

Food allergies

Other allergies

Special dietary needs

Additional medical information

Questions or Comments

Father's Name

Cell Phone

Email

Highest Level of Education Attained

Mother's Name

Cell Phone

Email

Highest Level of Education Attained

Intended Student Start Date

What is the first language this child learned to speak?

What language does this child speak most often outside of school?

What language do people usually speak in this child’s home?

Is this student currently under suspension/expulsion from another school?

Has this student previously received special education services?

Is this student currently receiving special education services?

I give my consent for emergency medical treatment for my child. In the event of illness or injury requiring emergency treatment, I give permission for the school authorities to take action.

I, the parent, hereby give my consent to all photographs, audio recordings, academic work, and/or video recordings taken of me or my minor child by Annoor Academy of Knoxville staff or their designee.

Is there anyone who DOES NOT have permission to pick up student? (Please list name and relationship)

Alternative Contact / Pickup (Name and Phone number)

Tuition Payment Method

Account holders name as shown on account

Banking Routing Number

Bank Account Number

Credit Card Number

cvv (code on back of card)

Card Number Expiration Date:

Cardholder Zip Code from credit card billing address:

Electronic Signature

Student Name

Birth Date

Gender

Address

City

State

Zip

Current School

Current Grade

Medical issues

Medical needs

Medication allergies

Food allergies

Other allergies

Special dietary needs

Additional medical information

Questions or Comments

Father's Name

Cell Phone

Email

Highest Level of Education Attained

Mother's Name

Cell Phone

Email

Highest Level of Education Attained

Intended Student Start Date

What is the first language this child learned to speak?

What language does this child speak most often outside of school?

What language do people usually speak in this child’s home?

Is this student currently under suspension/expulsion from another school?

Has this student previously received special education services?

Is this student currently receiving special education services?

I give my consent for emergency medical treatment for my child. In the event of illness or injury requiring emergency treatment, I give permission for the school authorities to take action.

I, the parent, hereby give my consent to all photographs, audio recordings, academic work, and/or video recordings taken of me or my minor child by Annoor Academy of Knoxville staff or their designee.

Is there anyone who DOES NOT have permission to pick up student? (Please list name and relationship)

Alternative Contact / Pickup (Name and Phone number)

Tuition Payment Method

Account holders name as shown on account

Banking Routing Number

Bank Account Number

Credit Card Number

cvv (code on back of card)

Card Number Expiration Date:

Cardholder Zip Code from credit card billing address:

Electronic Signature