Clovis Nazarene School
“A Child’s Place to Succeed”
2017-2018

CHILD INFO:  First Name:  ________________________________ Last Name:  ________________________________
Child’s Address:  ______________________________________________City & State:  __________________Zip:  _______
      [    ] Male       [    ] Female      	Date of Birth (mm/dd/yy):  ____________________  Age:  ________________

HEALTH INFORMATION:  Allergies [   ] Yes  [   ]  No    If yes, please list foods and/or medicines the child is allergic to.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Any other medical condition?  If yes, please explain._____________________________________________________________
_______________________________________________________________________________________________________

FATHER/GUARDIAN #1 First Name: __________________________Last Name:  ____________________________
Address:  _________________________________________________City & State:  ____________________Zip:  ________
Home Phone: (             )_____________________________  Cell Phone:  (              )__________________________________
Cellular Provider (needed to receive text alerts): [   ] Plateau  [   ] Sprint  [   ] Verizon  [   ] Other _____________________
Employer: ________________________________________________ Work Phone:   (               )__________________________
Employer’s Address:  ___________________________________ ________________________________________________  
Marital Status:  [   ] Married   [   ] Single  [   ] Divorced  [  ] Separated  [   ] Widowed  
E-Mail Address:_________________________________________________________________________________________

MOTHER/GUARDIAN #2 First Name: _________________________Last Name:  ____________________________
Address:  _________________________________________________City & State:  ____________________Zip:  ________
Home Phone: (             )_____________________________  Cell Phone:  (              )__________________________________
Cellular Provider (needed to receive text alerts): [   ] Plateau  [   ] Sprint  [   ] Verizon  [   ] Other _____________________
Employer: ________________________________________________ Work Phone:   (               )__________________________
Employer’s Address:  ___________________________________ ________________________________________________  
Marital Status:  [   ] Married   [   ] Single  [   ] Divorced  [  ] Separated  [   ] Widowed  
E-Mail Address:_________________________________________________________________________________________

PLEASE CIRLE THE GRADE THAT YOUR CHILD WILL BE 
ENTERING FOR THE 2017-2018 SCHOOL YEAR:

Mesa Elementary:	Grade:    K     1     2     3     4     5	

Zia Elementary:
	
Grade:    K     1     2     3     4     5	

Please be sure at least two people are marked as emergency contacts other than the parents/guardians.										           (Please check all that apply)
Name:	Relationship:	Phone #:	Lives With:	Emergency:	Pick-Up:	

	Father/Guardian #1					

	Mother/Guardian #2					

	Emergency Contact #1			X	X	

	Emergency Contact #2			X	X	

						

						
Child’s Doctor

	Doctor			X		

•	I give my permission for EMERGENCY MEDICAL TRANSPORTATION OR TREATMENT 
(If parents or emergency contacts cannot be reached):     
[   ] Yes   [   ] No

•	I give my permission for Neosporin to be applied to my child if needed.  
[   ] Yes   [   ] No 

•	I give my permission for my child to ride on the bus.  
[   ] Yes   [   ] No

•	I give my permission for my child’s photo to be used for the CNS web page and Facebook page.
[   ] Yes   [   ] No

•	I have read and understand the 2017-2018 Parent Handbook.  
[   ] Yes   [   ] No

___________ (Please Initial) **AS STATED IN THE HANDBOOK, IF YOUR CHILD IS NOT PICKED UP BY 5:30 P.M. A LATE FEE OF $5.00 PER MINUTE WILL BE CHARGED TO YOUR CHILD’S ACCOUNT.

PARENT’S SIGNATURE: _____________________________________________ DATE __________________

I hereby authorize Clovis Nazarene School to initiate credit/debit card charges to the below-referenced credit/debit card account.  I understand it is my responsibility, as the cardholder; to keep a reliable payment source on file at all times to avoid any additional fees for payments returned.  If there is a payment arrangement made between an outside party and/or two separate households, each cardholder will need to complete a separate Tuition Express form.

CREDIT/DEBIT CARD:

Cardholder Name: _______________________________________Phone Number:  ___________________

Address:  ________________________________________City & State:  ________________Zip:  ________

Card Number: _______________________________________ Expiration Date: ______________________

Cardholder Signature: ____________________________________________ Date: ____________________

For Office Use Only:

Date Received:

Employee Initials: