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Open Seas Learning Academy

8103 Indrio Rd. | Fort Pierce, FL 34951 | 772-202-2168

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Program Registration

Student's First Name

Student's Last Name

Student's Grade

Ethnicity

Hispanic or Latino

Non-Hispanic or Latino

Prefer not to answer

Student's Birthday

Race

Student's Address

Gender

Enrollment for

Parent/Caregiver Information

Parent/Caregiver Name

Relationship to Student

Parent's Email

Parent/Guardian Address

Phone

Parent/Caregiver Name 2

Relationship to Student

Parent's Email

Parent/Guardian Address

Phone

Information About Student

Please provide information about your child's health that may affect school perfomance or attendance. (ex Allergies, autism, seizures, developmental delays, etc).

Please list any additional information here about your student. You may include information about ESE programs and services they are receiving, any special likes that they may have, ways to calm them during a outburst, or anything else you think we should know.

Is your child toilet trained?

Is it ok to photograph your child(ren) to use in publications, new releases, online, social media, and other communications related to the mission of Open Seas Learning Academy?

Yes, it is ok.

No, do not photograph my child.

Please include the first and last name and phone number of anyone who is allowed to pick up your student.

How did you hear about us?

I would be interested in information about . . .

Before Care

After Care

Attending Church

Summer Camp

I understand that my student is not guaranteed enrollment by filling out this form. I also agree to the following:

My child and I will adhere to all Open Seas Learning Academy rules.

That myself or a representative will volunteer 25 hours per year.

That I will pay all costs associated with my child attending the program.

If my child has not attended an Open Seas Learning Academy program in the past, I will be required to pay a $75 non-refundable fee to hold their spot. The fee will be credited towards the program once they start.

I agree to the terms & conditions

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