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 NameLast Name
Nickname
Birthday*

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

First NameLast Name
E-mail*
Cell Phone*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Place of Work
Work Phone

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

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Place of Work
Work Phone

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

First NameLast Name
Person One Relationship *
Person One Phone*

Area CodePhone Number
Emergency Contact Person Two

First NameLast Name
Person Two Relationship
Person Two Phone

Area CodePhone Number
Emergency Contact Person Three

First NameLast Name
Person Three Relationship
Person Three Phone

Area CodePhone Number
Physician's Name*
Physician's Number*

Area CodePhone Number
Should be Empty:

Student's Information