W. K. Jackson Leadership Academy

Enrollment Form 2024-2025

(Be sure to submit required documentation fto the W. K. Jackson Leadership Academy office for completion of enrollment: Birth Certificate, Immunizations, Current Proof of Address, and Social Security Card.

Please Fill Out The Enrollment Form Below

Child's Legal First Name

Child's Middle Name

Child's Legal Last Name

Child's Preferred Name

Social Security Number:

Gender: _____Male _____Female

Home Street Address

Apt. #

City

Zip Code

Date of Birth (MM-DD-YYYY)

Grade Entering

Is English your household's primary language: _____Yes _____No

Last School Attended:

Date Last Attended:

Last Grade Completed:

If Other, Name and Relationship:

Legal/Custody Papers?

Yes

Mother's First Name

Mother's Last Name

Mother's Home Phone Number

Email address

Mother's Street Address

Mother's City of Residence

Mother's Cell Phone

Mother's Place of Employment

Mother's Work Phone

Father's First Name

Father's Last Name

Father's Home Phone Number

Email address

Father's Street Address

Father's City of Residence

Father's Cell Phone

Father's Place of Employment

Father's Work Phone

Guardian's First Name

Guardian's Last Name

Guardian's Home Phone Number

Guardian's Street Address

Guardian's City of Residence

Guardian's Cell Phone

Guardian's Place of Employment

Guardian's Work Phone

1st Emergency Contact (First Name):

1st Emergency Contact (Last Name):

1st Emergency Contact (Phone Number): Copy

Relationship to Child: Copy

2nd Emergency Contact (First Name):

2nd Emergency Contact (Last Name):

2nd Emergency Contact (Phone Number): Copy

Relationship to Child:

3rd Emergency Contact (First Name):

3rd Emergency Contact (Last Name):

3rd Emergency Contact (Phone Number):

Relationship to Child:

Reaquired field:

Student's Physician

Physician's Phone Number

Hospital Preference

IF AT ANY TIME THIS INFORMATION CHANGES, PLEASE NOTIFY THE OFFICE.

Transportation

Health History

Email a copy to

optional

Required Fields