WILLIAMSBURG ACADEMY ENROLLMENT FORM School Term _____________
Student Information
1. Student’s Name: _________________________ _______________________ ________________ Entering Grade ______
Last Name First Name Middle Name
Preferred Name: ______________________ SSN: ______/_____/_____ Gender: ____ Date of Birth _____/_____/________
mm dd yyyy
Allergies to medication: __________________________________________________________________________________
Allergies to food: _______________________________________________________________________________________
Medications for long term illness: ___________________________________________________________________________
Relevant Medical Information: _____________________________________________________________________________
May student be given Motrin at school? Yes/ No May student be given Tylenol at school? Yes/No
Physician: _____________________________________________ Phone Number: ___________________________________
Health/Accident Insurance Provider: ________________________________________ Policy Number: ____________________
2. Student’s Name: _________________________ _______________________ ________________ Entering Grade ______
Last Name First Name Middle Name
Preferred Name: ______________________ SSN: ______/_____/_____ Gender: ____ Date of Birth _____/_____/________
mm dd yyyy
Allergies to medication: __________________________________________________________________________________
Allergies to food: _______________________________________________________________________________________
Medications for long term illness: ___________________________________________________________________________
Relevant Medical Information: _____________________________________________________________________________
May student be given Motrin at school? Yes/ No May student be given Tylenol at school? Yes/No
Please Complete If Different From Above
Physician: _____________________________________________ Phone Number: ___________________________________
Health/Accident Insurance Provider: ________________________________________ Policy Number: ____________________
3. Student’s Name: _________________________ _______________________ ________________ Entering Grade ______
Last Name First Name Middle Name
Preferred Name: ______________________ SSN: ______/_____/_____ Gender: ____ Date of Birth _____/_____/________
mm dd yyyy
Allergies to medication: __________________________________________________________________________________
Allergies to food: _______________________________________________________________________________________
Medications for long term illness: ___________________________________________________________________________
Relevant Medical Information: _____________________________________________________________________________
May student be given Motrin at school? Yes/ No May student be given Tylenol at school? Yes/No
Please Complete If Different From Above
Physician: _____________________________________________ Phone Number: ___________________________________
Health/Accident Insurance Provider: ________________________________________ Policy Number: ____________________
4. Student’s Name: _________________________ _______________________ ________________ Entering Grade ______
Last Name First Name Middle Name
Preferred Name: ______________________ SSN: ______/_____/_____ Gender: ____ Date of Birth _____/_____/________
mm dd yyyy
Allergies to medication: __________________________________________________________________________________
Allergies to food: _______________________________________________________________________________________
Medications for long term illness: ___________________________________________________________________________
Relevant Medical Information: _____________________________________________________________________________
May student be given Motrin at school? Yes/ No May student be given Tylenol at school? Yes/No
Please Complete If Different From Above
Physician: _____________________________________________ Phone Number: ___________________________________
Health/Accident Insurance Provider: ________________________________________ Policy Number: ____________________
5. Student’s Name: _________________________ _______________________ ________________ Entering Grade ______
Last Name First Name Middle Name
Preferred Name: ______________________ SSN: ______/_____/_____ Gender: ____ Date of Birth _____/_____/________
mm dd yyyy
Allergies to medication: __________________________________________________________________________________
Allergies to food: _______________________________________________________________________________________
Medications for long term illness: ___________________________________________________________________________
Relevant Medical Information: _____________________________________________________________________________
May student be given Motrin at school? Yes/ No May student be given Tylenol at school? Yes/No
Please Complete If Different From Above
Physician: _____________________________________________ Phone Number: ___________________________________
Health/Accident Insurance Provider: ________________________________________ Policy Number: ___________________
6. Student’s Name: _________________________ _______________________ ________________ Entering Grade ______
Last Name First Name Middle Name
Preferred Name: ______________________ SSN: ______/_____/_____ Gender: ____ Date of Birth _____/_____/________
mm dd yyyy
Allergies to medication: __________________________________________________________________________________
Allergies to food: _______________________________________________________________________________________
Medications for long term illness: ___________________________________________________________________________
Relevant Medical Information: _____________________________________________________________________________
May student be given Motrin at school? Yes/ No May student be given Tylenol at school? Yes/No
Please Complete If Different From Above
Physician: _____________________________________________ Phone Number: ___________________________________
Health/Accident Insurance Provider: ________________________________________ Policy Number: ___________________
Family Information
Student resides with: Father Mother Both Other
Father’s Information Mother’s Information
_____________________, ________________, _____ _____________________, _______________, ____
Last Name First Name MI Last Name First Name MI
Preferred Name: ______________________________ Preferred Name: ____________________________
Address __________________________________ Address __________________________________
(If Different)
___________________, __________, __________ _______________________, _______, _________
City State Zip City State Zip
Home Email: ______________________________ Home Email: ______________________________
(If Different)
Cell Phone: ______________ Pager ___________ Cell Phone: ______________ Pager ___________
Employed By: ______________________________ Employed By: _____________________________
Business Phone (1) _________________ext. _____ Business Phone (1) ________________ ext. _____
Business Phone (2) _________________ ext. _____ Business Phone (2) ________________ ext. _____
Business Email: _____________________________ Business Email: ____________________________
Allowed to pick up child ____ Emergency Contact _____ Allowed to pick up child ______ Emergency Contact _____
Step Mother’s Information (If Applicable) Step Father’s Information (If Applicable)
_____________________, ________________, _____ _____________________, _______________, ____
Last Name First Name MI Last Name First Name MI
Preferred Name: ______________________________ Preferred Name: ____________________________
Cell Phone: ______________ Pager ___________ Cell Phone: ______________ Pager ___________
Employed By: ______________________________ Employed By: _____________________________
Business Phone (1) _________________ext. _____ Business Phone (1) ________________ ext. _____
Business Phone (2) _________________ ext. _____ Business Phone (2) ________________ ext. _____
Business Email: _____________________________ Business Email: ____________________________
Allowed to pick up child _____ Emergency Contact ____ Allowed to pick up child ______ Emergency Contact _____
Emergency Contact Information
Contact Name ___________________________________________________ Relation _______________________________
Home Phone __________________________ Business Phone ____________________ Cell Phone _____________________
Contact Name ___________________________________________________ Relation _______________________________
Home Phone __________________________ Business Phone ____________________ Cell Phone _____________________
Payment Plan
____ 10 month plan (August – May) (required with incentive plan) ____12 month plan (June-May)
____ Twice a year (August 1 and January 1) ____ Payment in Full (August 1)
Building/Maintenance Fee
I/We pledge and agree to pay a Building/Maintenance Fee of Five Hundred Dollars ($500) to Williamsburg Academy. I/We understand that this is a one time fee imposed on each family whenever the first child becomes enrolled at WA
The terms of the agreement are stated below:
$200.00 upon signing this agreement or before the first day of school
$100.00 for the next three (3) consecutive years after the enrollment of the first child due at registration or before the first day of school
Medical Treatment Consent
I recognize that as a result of participation in student activities, medical treatment on an emergency basis may be necessary. I further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may be deemed necessary under the then existing circumstance.
Family Education Rights and Privacy Act (FERPA)
I hereby grant Williamsburg Academy permission to make video/audio recordings, take photographs, and publish my child’s name and/or picture in newspapers, honor roll lists, Williamsburg Academy’s web site, and other academic distributions.
Field Trip Permission
I give my permission for my child to go on any field trip within the state of SC that is taken this school year.
I understand that all field trips will be supervised, and all precautions taken to avoid accidents. However, in the event of an accident, I will not hold either Williamsburg Academy or any chaperone responsible for such accident with exception to any mandatory liability insurance or premises liability that might be applicable to the vehicle in which my child is riding or the premises to which they might be taken. Any field trip taken out of State or a trip involving an overnight stay will require additional parental permission.
…………………………………………………………………………………………………………………………………………
I understand that the rules and regulations for a student at Williamsburg Academy are published in the WA handbook. I agree to read the handbook and abide by all rules and regulations contained therein. If this application for admission is accepted, I agree to pay the full tuition as long as I remain a resident of this area and as long as my child continues to attend the Academy. In the event that the child’s residence shall be removed from the area served by the Academy prior to the first day of school in the 2009-2010 session, the $100 registration fee will be refunded. After this, no refunds will be made. I further agree that if I withdraw my child from the Academy after the school year begins, the tuition due for the month in which the child withdraws must be paid in full.
A $100 registration fee per child must accompany this application. On the monthly payment plan, tuition is due on the first day of each month, but no later than the 20th. A $10.00 service charge will be added on the 21st. Any family falling delinquent over (60) days will result in withdrawal.
____________________________________________________________________________ ________________
SIGNATURE OF PARENT OR LEGAL GUARDIAN RESPONSIBLE FOR PAYMENT Date
For Office Use Only
____ Registration Fee $100 x ____ = $_______
____ Building Fund $_______
____ Consumable Fee $50 x ____ = $ ______
____ Technology Fee $50 x ____ = $ ______
____ Honors Fee $100 x ____ = $_______
____ Other ________ $______
Total Paid $________