Wesley Academy Registration Form

Wesley Academy Registration Form

315 E. Elm Street, Hillsboro, TX 76645 (254)582-2342
Student's Information
Student's Name *

First Name Last Name
Nickname
Birthday *

Month Day Year
Sex *
Which hand does the child use the most? *
Primary Care Giver's Information
Name *

First Name Last Name
E-mail *
Cell Phone *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone

Area Code Phone Number
Place of Work
Work Phone

Area Code Phone Number
Alternative Caregiver's Information
E-mail
Cell Phone

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone

Area Code Phone Number
Place of Work
Work Phone

Area Code Phone Number
Program Information
How did you hear about Wesley Academy?
Religious Affiliation
Emergency Information
Emergency Contact Person One *

First Name Last Name
Person One Relationship *
Person One Phone *

Area Code Phone Number
Emergency Contact Person Two

First Name Last Name
Person Two Relationship
Person Two Phone

Area Code Phone Number
Emergency Contact Person Three

First Name Last Name
Person Three Relationship
Person Three Phone

Area Code Phone Number
Physician's Name *
Physician's Number *

Area Code Phone Number
Should be Empty:

Student's Information