KEMPER ACADEMY

Application for Admission

Date _______________________ Grade ________________ Soc. Sec. # ____________

Student's Name _____________________________________ Age _________________

Home Address___________________________________________________________

City State Zip

County ______________________________________Beat # _____________________

Birth Record ____________________________________________________________

Month Day Year City County State

Home Phone #_______________Mom’s Cell #___________Dad’s Cell #____________

Father or Guardian's Name__________________________________________________

First Middle Last

Father's Employer_________________________________________________________

Company Name Phone #

Mother or Guardian's Name_________________________________________________

First Middle Last

Mother's Employer________________________________________________________

Company Name Phone #

Email Address: ______________________________ please check often information will be sent on school happenings.

*******************KINDERGARTEN AND FIRST GRADE ******************

Please bring a CERTIFIED COPY OF YOUR BIRTH CERTIFICATE and a CERTIFICATE OF COMPLIANCE from your doctor or Health Department at the time of registration verifying that your child has had the required immunizations.

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ALL STUDENTS

I understand that when my child is enrolled as a student in Kemper Academy, he or she is subject to the rules and regulations of Kemper Academy.

Acceptance of new students is subject to the approval of the Kemper Academy Board of Directors.

I hereby give permission for my child to take part in all school activities and absolve the school from any liability because of any injury to my child at school or to and from school or during school activities. I hereby agree to the terms of this application.

Parent or Guardian's Signature_______________________________________________