Virtual Academy Emergency Contact and Medical Form

Student Information

Student Name*

First Last

Student Date of Birth*

Parent/Guardian Information

Parent/Guardian Name*

First Last

Email*

Day Phone*

Evening Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Add a 2nd Parent/Guardian?

Yes

If yes, an account will be verified/created

2nd Parent/Guardian Information

Parent/Guardian Name*

First Last

Email*

Day Phone*

Evening Phone

Same address as Parent/Guardian #1*

Yes
No

Address*

Street Address Address Line 2 City State ZIP Code

Alternate Contact

(If we are unable to reach a contact listed above)

Alternate Emergency Contact*

First Last

Relationship to Student*

Alternate Emergency Contact Phone*

Does the student have special considerations that we should be aware of?*

(ex: learning differences, medical conditions that may impact participation, etc)

Yes
No

Please explain:*

Technology

How will your student be accessing class?

check all that apply

Computer- Mac
Computer- PC
iPad/Tablet
other

Please describe:

Does your student have access to secure and reliable internet?

Yes
No

Tell us more

Acknowledge and Agree to Registration Terms

As part of CTC's commitment to child safety, all online classes will be recorded.

Click here for Virtual Academy Policies

I have read and agree to CTC's online child safety policies and understand that classes will be recorded for safety and archival purposes

Yes

Photo Release*

Yes, I give my permission for photos/videos of my child(ren)'s participation in Virtual Academy to be used for promotional or grant development needs.
I understand that all classes will be recorded for safety/archival purposes but I DO NOT give permission for photos/videos of my child(ren) to be used for promotional or grant development needs.

I have read and accept the Virtual Academy Policies*

Click here for Virtual Academy Policies

Yes

Comments

This field is for validation purposes and should be left unchanged.

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Virtual Academy Emergency Contact and Medical Form

Student Information

Parent/Guardian Information

2nd Parent/Guardian Information

Alternate Contact

Technology

Acknowledge and Agree to Registration Terms