Lagoon Academy

Student Name (first and last)*

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Student Date of Birth*

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List Your Child's Medical Conditions or Allergies (If none, please type N/A)*

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Parent First Name*

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Parent Last Name*

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Street Address*

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City*

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State*

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Zipcode*

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E-mail Address*

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Primary Phone Number*

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Alternate Phone Number*

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Emergency Contact Name*

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Emergency Contacts Relationship to Student*

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Emergency Contacts Primary Phone Number*

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Emergency Contacts Alternate Phone Number*

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All Adults Authorized to Pick Up Student (First and Last name of each; separate each with a comma)*

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I've read the Behavioral Policy and I agree to the rules and procedures*

I've read the indemnification and hold harmless statement and I agree to the terms and conditions*

I acknowledge that refunds will only be granted up to 3 weeks prior to start of session, and that no refunds will be issued after that time.*

How did you hear about ELC's Lagoon Academy?*

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Any Additional Notes or Comments

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