Sankofa Registration & Enrollment Form - Sankofa Achievement Center, Inc.

Sankofa K-12 Registration & Enrollment Form

K-12 Registration & Enrollment Form

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First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of Birth:

Gender

Male

Female

Previous School (if any):

Guardian Name:

Relationship to Student:

Phone Number:

Home Address (if different from student):

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Contact Name:

Relationship to the Student:

Phones Number:

Does the student have any allergies?:

Yes

No

If yes, please list:

Does the student have any medical conditions that we should be aware of?:

Yes

No

If yes, please specify:

Primary Physician Name:

Phone Number:

Health Insurance Provider:

Policy Number:

I certify that the above information is correct to the best of my knowledge.

Yes

No

Signature: (Type Full Name)

Documents Submitted:

Birth Certificate

Proof of Address

Immunization Records

Other

Date