Registration Form – Jamaica Autism Academy

SECTION 1: STUDENT INFORMATION

First Name of Student

Last Name of Student

Date of Birth (DD/MM/YYYY):

Gender:

Male

Female

Other

TRN # (if applicable):

Address

Address Line 1

Address Line 2

City

Parish

Zip Code

Country

Nationality:

SECTION 2: PARENT/GUARDIAN INFORMATION

Primary Parent/Guardian Full Name:

Relationship to Student:

Phone Number (Mobile):

Phone Number (Home):

Email Address

Occupation:

Secondary Contact Name & Relationship (optional):

Second Contact Phone Number:

SECTION 3: MEDICAL & NEURODEVELOPMENTAL INFORMATION

Has your child been formally diagnosed with any neurodevelopmental or neurodiverse condition(s)?

Yes

If yes, please check all that apply:

Diagnosis Date (if applicable):

Is your child currently on any medication?

Yes

If yes, please specify:

Does your child have any allergies?

Yes

If yes, please specify:

SECTION 4: SUPPORT SERVICES & HISTORY

Previous School Attended (if any):

Has your child received any of the following? (Check all that apply):

Please attach any relevant medical or psycho-educational reports.

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SECTION 5: PROGRAM INTEREST

What type of program are you registering for?

Full-time Education

Therapy Services Only

After-School/Vocational Program

Preferred Start Date:

SECTION 6: EMERGENCY CONTACT

Name:

Relationship to Student:

Phone Number:

SECTION 7: CONSENT & DECLARATION

I declare that the information provided above is accurate to the best of my knowledge. I
understand that Jamaica Autism Academy may request additional documentation to
complete the registration process.

I give permission for my child to participate in all academic and therapeutic activities
provided by the Jamaica Autism Academy, and for staff to seek emergency medical care if
necessary.

Signature of Parent/Guardian:

Date:

Please return the completed form along with the following documents:

Copy of Birth Certificate

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Diagnosis/Assessment Reports

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Immunization Record

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Passport-sized Photograph (2 copies)

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School Reports (if applicable)

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