Full Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Tuition Fees *

I understand tuition fees are due every Monday, by 6 p.m.

Late Fees *

I understand that a $10 late fee will be applied to any unpaid balance Tuesday morning.

Withdrawal or Change of Status *

I understand that I must notify the Director or Assistant Director of my child(ren)'s withdrawal or change of status.

Full Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

I'm enrolling my child as follows: *

Full-time

Part-time

After-school Care

Drop-in

Please mark any item below that your child has an allergy to. *

Milk

Eggs

Nuts

Fish

Strawberries

Gluten

Latex

Ants

Mosquitos

None

Other (not listed)

Has your child ever had any surgery? *

No

Yes

Has your child ever had a serious accident? *

No

Yes

Does your child have any vision problems? *

No

Yes

Does your child have any hearing problems? *

No

Yes

Has your child ever been in group care (childcare center or home center)? *

No

Yes

Has your child been treated for any of the following? Please select accordingly. *

Autism

Behavioral disorders

Developmental delays

Attention deficit disorder

Consistent vomiting or spitting up

HIV/Aids

Diabetes

Seizures

None

Does your child have any physical, emotional, or developmental needs? Any behavioral characteristics? *

No

Yes

Does your child have any food restrictions for any medical or religious reasons? *

No

Yes

Is your child potty trained? *

Diapers

In Training

Fully Potty Trained

Immunization Records Requirement *

I understand that I must provide my child's immunization certificate from their physician or the local health department within 30 days of enrollment.

Immunization Update *

I understand that my child must have a current immunization form on file at all times and therefore I must provide an updated certificate when needed.

Updated Records Acknowledgement *

I understand it is my responsibility to keep my child's records current to reflect any significant changes as they occur.

Pick-up Acknowledgement *

I understand my child will not be able to enter or leave the school without being escorted by the parent or person authorized by the parent.

Permission to Transport Child *

School-age Children Only: I give permission for my child to be transported by the Daily Blessing Academy buses.

Not Applicable

School-age Children Only: Please select the school that your child needs transportation for. *

Dorothy Height Elementary-1458 Benning Dr, Columbus, GA 31903

Martin Luther King, Jr. Elementary- 1566 350 30th Ave, Columbus, GA 31903

Brewer Elementary- 2951 Martin Luther King Junior Blvd, Columbus, GA 31906

J.D. Davis Elementary- 1822 Shepherd Dr #4098, Columbus, GA 31906

South Columbus Elementary- 1964 Torch Hill Rd #2798, Columbus, GA 31903

Key Elementary- 2520 Broadmoor Dr #3419, Columbus, GA 31903

Not Applicable

Emergency Contact #1 *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact #2 *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact #3 *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country