Application for Admission

Meadow Oaks Academy — Mesquite Campus

1412 S Belt Line Rd, Mesquite, TX 75149 | 972-285-6895 | Director: Lora (Lori) Sargeant

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This Application is for the Mesquite Campus Only This enrollment application is exclusively for Meadow Oaks Academy — Mesquite Campus (1412 S Belt Line Rd, Mesquite, TX 75149). Meadow Oaks Academy operates four campuses across the Dallas–Fort Worth area. If you are enrolling at a different campus, please contact that campus directly for the correct application.

Other campuses: Dallas Montessori Campus | Colorado Springs Campus | Garland Campus

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Admission Information

Date of Admission

Date of Withdrawal

Child's Information

Child's Last Name *

Child's First Name *

Middle Name

Child's Home Address

Date of Birth *

Child's Gender

Male Female

Who Has Legal Custody of Applicant?

Custody Documents on File

Yes No

Father Deceased – Date

Mother Deceased – Date

Parents Separated – Date

Parents Divorced – Date

Meals & Attendance Schedule

Meals: I understand that the following meals will be served to my child: Breakfast, Lunch, and PM Snack.

Days and times my child will be in care:

Attend	Day	A.M. Arrival Time	P.M. Departure Time
	Monday
	Tuesday
	Wednesday
	Thursday
	Friday

Parent / Guardian #1

Full Name *

Home Address (if different from child)

Primary Phone *

Work Phone

E-Mail Address *

Social Security Number

Driver's License # (TX)

Employer

Employer Address

Parent / Guardian #2 (or Step Parent)

Full Name

Home Address (if different from child)

Primary Phone

Work Phone

E-Mail Address

Social Security Number

Driver's License # (TX)

Employer

Employer Address

Emergency Contacts — Authorized to Pick Up Child

Please list all persons authorized to pick up your child in case of emergency.

#	Full Name	Relationship to Child	Home Address & Phone Number	TX DL #
1
2
3

Medical Information & Permissions

Permission to Apply (Parent Must Provide Product):

Sun Block

Yes No

Bug Spray

Yes No

Lotion

Yes No

Diaper Cream

Yes No

Permission to Apply for Minor Accidents (Parent Must Provide):

Hydrogen Peroxide

Yes No

Neosporin

Yes No

Long Term Medication #1

Long Term Medication #2

Diagnosed Allergy #1

Diagnosed Allergy #2

Diagnosed Allergy #3

Allergy Action Plan on File

Yes No

Allergy Action Plan Date

Previous or Current Serious Illness

Pediatrician Name

Pediatrician Office Address

Pediatrician Phone

Dentist Name

Dentist Phone

Can Your Child Swim Without Assistance?

Yes No

If No, What Type of Assistance Is Needed?

Things to Know / Special Care Needs

Parent/Guardian Gives Consent For:

Water Activities:

Does M.O.A. Have Permission to Take My Child's Picture or Video for School Activities, Projects, Name Tags, MOA Social Media, etc.?

Yes No

Authorization for Emergency Medical Attention:

In the event I cannot be reached to arrange for emergency medical care, I authorize the person in charge to take my child to:

Dallas Regional Hospital — 1011 N Galloway Ave, Mesquite TX 75149 Phone: 214-320-7000

Children's Medical Center — 1935 Medical District Dr, Dallas TX 75235 Phone: 214-456-7000

I Give Consent for Meadow Oaks Academy to Secure Any and All Necessary Emergency Medical Care for My Child

Yes, I give consent No

Language & Background Information

Language Other Than English Spoken at Home?

Yes No

If Yes, Which Language?

How Did You Hear About Meadow Oaks Academy?

Has Your Child Previously Attended MOA?

Yes No

If Yes, What Year?

Why Would You Like to Enroll Your Child at Meadow Oaks Academy?

Prior School History — Previous Preschools / Child Care Your Child Has Attended

Discipline History

Has the Student Ever Had Any Discipline Problems, Been Suspended, and/or Asked to Leave a Facility?

Yes No

If Yes, Please Explain

Health & Physical Information

Please List Any Mental, Emotional, or Physical Challenges That May Affect the Student's Activities or Progress

Any Limitations in Your Child's Physical Activities or Health Concerns the School Should Be Aware Of?

Who Lives at Home With the Student

Please list all members living at home and their relationship to your student.

Name	Age	Relationship to Child

Financial Responsibility

Financial Responsibility for Applicant Will Be Assumed By

If different from Mother and/or Father above, please provide the following information:

Name

Social Security #

Primary Number

Work Number

Address

City

State

ZIP

Tuition & Payment

Please review the Tuition and Fee Schedule and make the appropriate method of payment.

Private Pay Clients — Choose a Payment Option:

Weekly Semi-Monthly (on 1st & 16th of the month) Monthly (1st of the month)

CCA Clients: Must pay full copay on the 1st of each month, per CCA regulations.

Acceptable Forms of Payment:

Credit Card | Checks | Money Order | Tuition Express *** CASH is NOT an option ***

Correspondence Preference

All Information Regarding Student, Behavior, Transportation, and Correspondence Should Be Sent To:

Mother Father Both Other

If Other, Please Specify

Receipt of Written Operational Policies

I acknowledge receipt of the facility's operational policies, including those for (check all that apply):

Signature & Agreement

It is understood that this application is made to the terms of admission, acceptance by School Administration, and tuition rates are in effect at the time of entrance to Meadow Oaks Academy.

Meadow Oaks Academy does not discriminate on the basis of national or ethnic origin, race, gender, color, or disability in administrating its educational policies, financial assistance program or other school programs.

Parent/Guardian Signature (Type Full Name) *

Date *

Upon submission, a formatted PDF copy of this application will be emailed to you and the Meadow Oaks Academy admissions team at Lori, Kara, and accounting.