T.A.G. The Academic Gym Family and Student Information Form

Parent or Guardian's Information

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Preferred contact method

Phone

Emergency Contact Name

If none, say N/A

Emergency Contact Phone

If none, say N/A

Emergency Contact Relationship to Student

If none, say N/A

Is there anyone you might authorize to drop off or pick up the student? Please answer with yes or no.

If yes, then please list that person's full name, telephone number, and relationship to the student.

Student's Information

First Name

Last Name

Gender

Age

Birthday (Please click the calendar)

Current Grade Level (or grade level the student will be entering in September if enrolling during the summer)

(or grade level the student will be entering in September if enrolling during the summer)

School Name

Educational Diagnostic Testing History

Has the student been tested for any of the following:

If you selected "other" please explain.

If this field is not applicable, please enter N/A.

Diagnosis: After testing was the student diagnosed with any of the following

If you selected "other" please explain.

If this field is not applicable, please enter N/A.

Medical Information

Allergies (if any)

Please list any allergies we should be aware of. If none, please say n/a.

Chronic Conditions (if any)

Please list any chronic conditions we should be aware of. If none, please say n/a.

Any special instructions for Emergency Medical Treatment

Please list any special instructions for Emergency Medical Treatment we should be aware of. If none, please say n/a.

Program Goals and Expectations

What are the family’s goals for the student in this program?

Additional Information

Does the Student Require Any Accommodations? (Yes/No) If yes, please specify:

Is the Student Authorized for Photos/Videos to Be Taken During Activities? (Yes/No)

Special Interests or Hobbies

Documentation

Please upload any documentation you would like to share with us about the student's medical or educational testing history. You may also upload recent report cards or progress reports.

File upload

Please select the date and sign

Date picker

By checking the box, I hereby certify that the information provided above is accurate and complete to the best of my knowledge. Checking the box represents my signature.