The Refuge Academy Student Registration 2024-2025

2001 Campbell Station Pkwy A-6, Spring Hill, TN 37174 Director: Jazmin Barajas 615-241-5660

Your name *

Email address *

Child's Name *

Child's Preferred Name:

Child's Birthdate (mm/dd/yyyy) *

Child's Gender *

Address *

Mother's Name:

Mother's Contact Phone:

Mother's Employer:

Father's Name:

Father's Contact Number:

Father's Employer:

Secondary Email Address:

Does your child have any allergies? If yes, please list below. *

Does your child take any medication on a regular basis? If yes, please list below.

Child lives with: *

Are there any custody issues we should be aware of? *

Is your child potty trained?

In case you are not able to be reached, who is an alternative contact we can call? *

Alternative Contact's phone number: *

Please list all people (excluding parents/guardians) who are permitted to pick up your child: *

Which days would you prefer for your child? *

Medical Information

Pediatrician: *

Pediatrician's Phone Number: *

Insurance Provider: *

Policy #: *

In case of emergency, do you authorize The Refuge Academy to contact emergency personnel (ambulance/fire/police) on behalf of your child and their immediate need. Every effort will be made to contact the parent/guardian should such a situation occur. *

A copy of your child's immunization record must be submitted before the child starts the program. There will be a document stating that you agree to this to sign at meet the teacher night or before your child's first day.

Is there any additional information we need to know about your child?

One of the steps to register our preschool with the state is to make parents aware that we are not required to be licensed by the state because students attend only two days per week, for not more than 6 hours per day. *

Do you acknowledge your awareness of the following statement:
THIS FACILITY IS NOT REQUIRED TO BE LICENSED BY THE STATE AS A CHILD CARE AGENCY.
There will be a document stating that you understand this to sign at meet the teacher night or before your child's first day.

Your child may be photographed or videoed at The Refuge Academy during normal preschool hours, field trips, and activities. *

Do you give permission for your child's photos and/or videos to be used in the school newsletter and/or any social media managed by The Refuge Church or The Refuge Academy. There will be a document stating that you agree to this to sign at meet the teacher night or before your child's first day.

How will you be paying the registration and supply fee? *

How did you hear about us?

Household members

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