ENROLLMENT

GLOBAL PURPOSE ACADEMY

(GPA) REGISTRATION / ENROLLMENT FORM
ALL FIELDS MUST BE COMPLETED. PLEASE DO NOT LEAVE ANYTHING BLANK. IF NOT APPLICABLE, PLEASE WRITE "N/A".
CHILD'S INFORMATION
Child's First Name: *
Child's Middle Name:
Child's Last Name: *
Date of Birth: *

Month Day Year
Date
Child's Age:
Gender

Female Male
Child Resides with:
Child's Home Address (Include Number & Street Name): *
City: *
State: *
ZIP Code: *

PARENT(S) / GUARDIAN(S) INFORMATION
MOTHER / GUARDIAN
First Name: *
Last Name: *
E-mail:
Mobile Phone: *
Home Phone:
Work Phone:
Home Address (Include Number & Street Name): *
City: *
State: *
ZIP Code: *
MOTHER'S / GUARDIAN'S WORK INFORMATION
Employer:
Work Phone:
Work E-mail:
Work Address (Include Number & Street Name):
City:
State:
ZIP Code:
FATHER
First Name:
Last Name:
E-mail:
Mobile Phone:
Home Phone:
Home Address (Include Number & Street Name):
City:
State:
ZIP Code:
FATHER'S WORK INFORMATION
Employer:
Work Phone:
Work E-mail:
Work Address (Include Number & Street Name):
City:
State:
ZIP Code:

OTHERS AUTHORIZED TO DROP OFF / PICK UP CHILD FROM GPA
Primary Contact
First Name: *
Last Name: *
E-mail:
Mobile Phone: *
Home Phone:
Work Phone:
Home Address (Include Number & Street Name): *
City: *
State: *
ZIP Code: *
Relationship to child & guardian: *
Secondary Contact
First Name:
Last Name:
E-mail:
Mobile Phone:
Home Phone:
Work Phone:
Home Address (Include Number & Street Name):
City:
State:
ZIP Code:
Relationship to child & guardian:
SPECIAL CONTACT INSTRUCTIONS
Comments:

OTHER EMERGENCY CONTACT (In case of illness or other emergency if parents cannot be reached)
Primary Contact
First Name: *
Last Name: *
Relationship to Child: *
E-mail:
Mobile Phone: *
Home Phone:
Work Phone:
Home Address (Include Number & Street Name): *
City: *
State: *
ZIP Code: *
Secondary Contact
First Name:
Last Name:
Relationship to Child:
E-mail:
Mobile Phone:
Home Phone:
Work Phone:
Home Address (Include Number & Street Name):
City:
State:
ZIP Code:
CHILD'S PEDIATRICIAN OR SOURCE OF HEALTH CARE
Physician's First Name: *
Physician's Last Name: *
Physician's E-mail:
Physician's Phone: *
Physician's Address (Include Number & Street Name): *
City: *
State: *
ZIP Code: *
Insured's Name:
Health Insurance Carrier:
Policy / Group#:
MEDICAL AUTHORIZATION
I give Global Purpose Academy p ermission to apply one or more of the following topical ointments / preparations to my child(ren) in accordance with the directions on the label of the container:
External Ointments / Preparations:

Wipes Band-aids Neosporin or similar ointment Bactine or similiar first aid spray Sunscreen Insect Repellent Non-perscription ointment (such as Vaseline)
MEDICAL EMERGENCY STATEMENT
I hearby give my consent to Global Purpose Academy (GPA) to authorize medical treatment for my child(ren) should it be necessary while my child(ern) is/are in GPA's care and GPA is unable to contact me immediately. I give permission for G PA to take my child(ren) to a hospital when I cannot be reached to secure medical attention and care for my child(ren) as may be necessary. I shall assume responsibility for payment for medical services.
Parent/Guardian Signature (type name):
Date:

Month Day Year
Date

NOTICE OF NO LIABILITY INSURANCE & ACKNOWLEDGEMENT
I understand that I am being informed by signing this acknowledgment that GPA does not carry liability insurance sufficient to protect my child(ren) in the event of an injury, etc.
Parent/Guardian Signature (type name):
Date:

Month Day Year
Date
ON-SITE CONSENT
I hearby give Global Purpose Academy (GPA) permission to allow my child(ren) to participate in on-site field play/activities (pavilion, black top, open field, etc.) at GPA.
OFF-SITE CONSENT
I hearby give Global Purpose Academy permission to take my child(ren) on excursions that might include the following type of activities: riding in vehicle (car, van or bus) and field-trips (zoo, park, restaurant, aquarium, etc.)
I understand that GPA will take every precaution (on-site and/or off-site) and care to insure my child's safety. Adults will provide proper supervision and will exercise every precaution to avoid accidents. I am aware of the risks associated with such activities, I agree to hold Global Purpose Academy, its officers, faculty and employees harmless against any liability arising as a result of his/her participation in these activities. If illness or injury should occur during his/her participation in these activities, I authorize medical treatment at an appropriate medical facility. I understand that a reasonable attempt to be contacted will be made prior to such medical treatment.
In case of emergency, contact (type name):
Emergency contact phone number:
Insurance Company:
Policy Number:
Parent/Guardian Signature (type name):
Parent/Guardian phone number:
Date:

Month Day Year
Date
CONSENT TO USE YOUR CHILD'S IMAGE
We may take photographs and/or videos of children at our school. We may use these images in GPA's printed publications, as well as on our website, e-newsletter and social media such as Facebook. We may also make video or webcam recordings for conferences, monitoring or other educational use. We need your permission before we can photograph or make any recordings of your child for promotional and/or educational purposes. Please sign below if you grant us permission to take photos / videos of your child.
Parent/Guardian Signature (type name):
Date:

Month Day Year
Date
CONSENT TO TEXT MESSAGE
For the purpose of quick communication, permission is requested for GPA teachers and staff to use text messaging as a communication tool for school information. GPA will only text important information related to the school and/or your child's behavior and class work. As would be the case with any texting, standard rates for texting would apply to any texts sent and would be the responsibility of the students and families. I give permission for GPA teachers and staff to use text messaging to send quick communication regarding school information to the following numbers. I understand and agree that GPA will not pay for any costs to students or Parents/Guardians associated with the sending or reception of messages to or from GPA teachers and staff.
Phone number for text messaging:
Parent/Guardian Signature (type name):
Date:

Month Day Year
Date

CHILD'S SCHEDULE & INTERESTS [the following information will help GPA understand & care for your child(ren)]
Names & ages of other children in family:
Are parents separated or divorced?

Yes No
Please note any allergies:
Please note any food restrictions:
Please note any medical issues:
What are some of your child's favorite foods:
Toilet & Independence
GPA is a school, therefore we require students age 3 and above to be FULLY toilet-trained and independent dressers. In order for your child to participate in the Preschool Program (age 3+) he/she must be completely toilet-trained and a self-dresser. Being toilet trained requires the following: • Children are aware of their need to use the bathroom and can recognize this in a timely manner to make it to the bathroom. • Children are able to clearly articulate their need to use the bathroom and/or change their. • Children are able to take care of all their toilet needs independently. This includes wiping themselves and being able to completely change on their own should an accident occur. • Students are expected to enter the bathroom stall alone without assistance (using the toilet, wiping, dressing, etc.) • Disposable pull-up pants may be worn only at nap time and the child must be able to put on and take off the pull-up and wipes him/herself without assistance. • Teachers do not change diapers or pull-ups. • When a child is toilet trained, we understand that an accident (an untimely recognition of need to use bathroom) may still occur, however, we do not consider it toilet trained if it occurs more often than every few months. • In the event of an accidental wetting, children will need to independently change themselves into dry clothes provided by the parent. Therefore, we ask that you bring a set of clean clothes with your child. • In the event of a bowel accident, parents will be called to change their child. • In the event that a child is not fully toilet trained and a wetting or bowel accident occurs 2 times within a 2 week period, a plan will need to be created that may include moving him/her to the Toddler Program until the child can take care of his/her needs independently. If absolutely necessary, staff members will wear latex gloves when dealing with any bodily fluids as a safety precaution. Do you acknowledge that your child is an independent toilet-user, dresser, able to wipe him/herself and wash their hands without assistance? *

Yes No N/A
Nap / Rest Habits
Does your child nap?

Yes No N/A
How long does your child nap / rest?
Student Information
What are some of your child's favorite activities:
Describe any areas of difficulty you would like your child to work on?:
Describe any special needs your child may have.
What is the most challenging situation for your child?
What frustrates your child?
What are your child's areas of opportunities?
What are your child's strengths?
Does your child get upset easily?
What upsets your child?
How do you calm your child down?
Do your tactics at home work?
Please describe your child's attitude and behavior:
Has your child ever been suspended from school? Please describe.
Has your child ever been dismissed from school due to their behavior? Please describe.
Please add any other special information that is important for GPA to care for your child:

STUDENT REFERRAL PROGRAM
GPA has an excellent Student Referral Program. After your referral has attended GPA for 90 days (3 months), you will receive a $250 tuition credit toward your next monthly tuition.

Referral Program Details: 1) Provide the contact information of your referral 2) Your referral must include your name on the referral and/or registration form 3) The new student must be active and attending GPA for at least 90 days (3 months) 4) You will receive a $250 tuition credit (after referral has been at GPA for 3 months) To facilitate referrals, we will provide you with promotional materials (brochures and cards). You may also refer people to GPA's website and GPA's Facebook page. Prospective parents/students may schedule a 30 minute appointment to meet with me and tour the school on Monday - Friday between the hours of 9am - 11am and again from 4pm - 6pm.
REFERRAL
Please provide the full name and contact information of the person who referred you to GPA.
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SIGNATURE
I have completed my child's registration application and answered all of the questions truthfully. I will read and sign the Parent Handbook within 7 days of the submission of my child's registration form.

(You may use your finger or mouse to sign your name).
Signature
Date: *

Month Day Year
Date
THANK YOU for choosing Global Purpose Academy to care for and educate your child to achieve excellence in everything and explore their purpose...
Tuition Rates: (Payments made via PayPal)
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Application Fee (one-time payment) $ 50.00

Annual Registration Fee $ 100.00

School Day: 7am - 3:30pm (weekly rate) $ 185.00

Number of Weeks

AfterCare Program: 3:30pm - 6:00pm (weekly rate). Friday 5pm $ 25.00

Number of Weeks

Extracurricular Program: 3:30pm - 6:00pm (weekly rate) - Friday 5pm $ 80.00

Number of Weeks

Total $ 0.00
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