TIPTON ACADEMY
Mother/ Guardian Information
Last Name: _________________________ First Name: ______________________
Address: _____________________   _________________       _________________  
City                                        State                   Zip Cell Number: ________________________ Home Number: ___________________________
 
Work Number: _______________________   Relationship to Student: __________________________________ 
 
LIST OTHER CHILDREN IN THE FAMILY
    Father/ Guardian Information
    Last Name: _________________________ First Name: ______________________
    Address: _____________________   _________________       _________ _________                                                                                                                            City                                        State                    Zip Cell Number: ________________________ Home Number: _________________________
 
Work Number: _______________________   Relationship to Student: __________________________________ 
 
NAME DATE OF BIRTH GRADE SCHOOL ATTENDING                                                
 
WITH WHOM DOES THE CHILD RESIDE?  Both Parents______   Mother_________   Father _______ Guardian_______
______ Stepmother       ______ Stepfather
PRESENT LIVING SITUATION: ____Own Home ____Renting Home   ____   Living with another family due to financial reasons
____ Car   ______Motel/Hotel    _____ Campsite/Trailer
 
Knowingly falsifying registration information is grounds for immediate removal of the child from Tipton Academy. I attest that the above information is accurate and complete to the best of my knowledge.
               Signature of Parent or Guardian Enrolling Student:
   ___________________________________________________________________   Date: ________ Relationship: ____________________________
Tipton Academy will not tolerate unlawful discrimination by or against students because of their race, color, creed, religion, height, weight, age, marital status, veteran status, citizenship, national origin, sex, handicap or disability, or any other factor prohibited by law.  This policy applies without exception. After investigation, persons who violate this policy are subject to appropriate sanctions for their conduct.