Student Life at Excelsior Preparatory School

Club Registration

Please fill out the following form to sign your student up for clubs.

 

  1. Student's Name*
    Student's full name is required
  2. Student's DOB*
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  3. Teacher's Name*
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  4. 2018-19 Grade Level*











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  5. Please check the box next to the club that you would like your child to be a member of for this academic year.








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  7. Parent's Name*
  8. Contact Number*
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  9. Parent's Email*
    Please enter a valid email address
  10. AUTHORIZED PICK-UP PERSON

    I hereby inform Excelsior Artz Preparatory School that the people listed below are authorized to pick up the above named child(ren) at anytime. Accordingly, Excelsior Artz Preparatory School is hereby instructed to release my child(ren) into the care of the following people whenever they come to our center.
  11. 1. Full Name, Relationship to Child, Phone Number
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  12. 2. Full Name, Relationship to Child, Phone Number
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  13. 3. Full Name, Relationship to Child, Phone Number
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  14. 4. Full Name, Relationship to Child, Phone Number
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  15. List any allergies that your child possesses that you are aware of:
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  16. Describe symptoms here:
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  17. Child's Primary Physician Name & Phone*
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  18. I am also aware that students may be withdrawn from a club at any time based on one or more of the following reasons: tardiness, poor behavior, poor grades, poor attendance, lack of participation, and lack of respect for the facilitator or other members. Excelsior Arts Preparatory School reserves the right to dis-enroll a student at any time for any reason listed or unlisted above.
  19. Parent's signature*
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