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SiFA (Science is Fun and Awesome)

Learning Academy Charter School


Registration Form SY 2019-2020
P.O. Box 9427 Tamuning, GU 96931
Tel: (671) 734-7432
Email: admin@sifalacs.com

Date: Student Name: (Last, First, MI)

Entering grade: Previous School:

Forms to be submitted: Date Received by:


submitted:
Registration Form

Birth Certificate or Passport

School records/transcripts
(Official withdrawal from previous school)
Report Card (Most recent)

Student Medical Information form

Updated Student PE form


(With physician’s signature on second page)

Updated Immunization record (with Annual


PPD or clearance from DPHSS, if positive)

If applicable: Notarized Legal Guardianship


Documents or Notarized Power of Attorney

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Student Information

Last Name ______________________ First Name___________________________ MI ______


Nickname __________________ Gender M ☐ F ☐ Birthdate _____________ Age ______
Birth Place______________________ Social Security #________________________
Home Phone #_________________ Cell Phone #_________________
Home Address _______________________________________________________________
_____________________________________________________________________________
Mailing Address ______________________________________________________________
_____________________________________________________________________________
Student Information
Parent Information

FIRST Parent – Relation to Student _______________


Last Name ______________________ First Name___________________________ MI ______
Home Address (if different from above) ___________________________________________
__________________________________________________________________________________
Mailing Address (if different from above) __________________________________________
__________________________________________________________________________________
Home Phone # __________ Cell Phone # __________ Email Address____________________
Occupation ________________ Employer _________________ Work Phone #_____________

SECOND Parent – Relation to Student _____________


Last Name ______________________ First Name___________________________ MI ______
Home Address (if different from above) ___________________________________________
__________________________________________________________________________________
Mailing Address (if different from above) __________________________________________
__________________________________________________________________________________
Home Phone # __________ Cell Phone # __________ Email Address____________________
Occupation ________________ Employer _________________ Work Phone #_____________

Legal Guardian – Relation to Student ______________


(Please provide notarized Legal Guardianship or Power of Attorney if student is not residing with
natural parents.)

Last Name ______________________ First Name___________________________ MI ______


Home Address (if different from above) ___________________________________________
__________________________________________________________________________________
Mailing Address (if different from above) __________________________________________
__________________________________________________________________________________
Home Phone # __________ Cell Phone # __________ Email Address____________________
Occupation ________________ Employer _________________ Work Phone #_____________

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Student Name: ___________________________________________
Grade: ________

Student Medical Information

Medical History:
Does your child have any health issues? ☐ Yes ☐ No
If yes, please specify:
__________________________________________________________________________________
__________________________________________________________________________________

Please indicate which of the following communicable disease(s) your child have/has had:
☐ Chicken Pox ☐ Diphtheria ☐ Measles ☐ German Measles
☐ Mumps ☐ Influenza ☐ Scarlet Fever ☐ Whooping Cough

Please indicate whether your child has any persistent problems with the following:
☐ Asthma ☐ Colds ☐ Coughs ☐ Headaches
☐ Stomachache ☐Hay Fever ☐ Tonsillitis ☐ Nosebleeds
☐Seizures

Does your child take any special medication for it? ☐ Yes ☐ No
If yes, please specify what medication:
__________________________________________________________________________________
__________________________________________________________________________________

Is your child up to date with his/her immunizations? ☐ Yes ☐ No

Has your child had any serious accidents that required him/her to be hospitalized? ☐ Y ☐ N
If yes, please specify:
__________________________________________________________________________________
__________________________________________________________________________________

Has your child had any operations? ☐ Yes ☐ No // If yes, please specify
__________________________________________________________________________________

Does your child wear glasses? ☐ Yes ☐ No // Date of last eye exam _____________________
Does your child have regular dental check-ups? ☐ Yes ☐ No // Date of last dental check-up
________________
Does your child have any hearing problems? ☐ Yes ☐ No // Date of last hearing exam
________________
Does your child have any allergies? ☐ Yes ☐ No // If yes, please specify
__________________________________________________________________________________
Does your child have any allergies to medicine? ☐ Yes ☐ No // If yes, please specify
__________________________________________________________________________________
☐ Long term medications prescribed by Medical Doctor
☐ Short term medication (Over the counter)

**Need written parental consent for the School Nurse or designated personnel to dispense
such medication**

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Emergency Information

In case of emergency, the school immediately contacts the parents. If parents


are not available, please provide the information below for the name(s) of the
person(s) to contact.

1. RELATION to the child ____________________________

Last Name ______________________ First Name___________________________ MI ______


Best Contact # (1) ____________________ Best Contact # (2) __________________
Home Address: __________________________________________________________________

2. RELATION to the child ____________________________

Last Name ______________________ First Name___________________________ MI ______


Best Contact # (1) ____________________ Best Contact # (2) __________________
Home Address: __________________________________________________________________

Physician Name: ______________________ Hospital/Clinic: ______________________


Clinic Phone # ______________________
Do you have medical insurance? ☐ If yes, please specify: __________________________

---------------------------------------------------------------------------------------------------------------------------

I hereby give my consent to the Administration of SiFA Learning Academy Charter


School to obtain emergency medical treatment for my child.

Parent Name: ____________________ Signature: _________________ Date: ________

I HEREBY CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND


CORRECT TO THE BEST OF MY KNOWLEDGE.

Parent Name: ____________________ Signature: _________________ Date: ________

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Student Name: ___________________________________________
Grade: ________

Photo/Video Release

Throughout the year, SiFA Learning Academy Charter School will be


cataloging events through pictures and videos. These pictures and videos are
to be used in various printed and electronic mediums such as newspaper ads,
brochures and websites. Please indicate whether or not SiFA LACS has
permission to use any pictures or videos of your child. Agreement would not
be restricted to the aforementioned media.

Please initial one:

____ Yes, I give SiFA LACS permission to use pictures and/or video of my child in the
aforementioned media.

____ No, I do not want pictures or videos of my child used in the aforementioned media.