MEMPHIS COLLEGE PRREP

Scholar Enrollment Application 2024-2025

We are thrilled that you have chosen Memphis College Prep as the school home for your child for the 2024-2025 academic year. Please complete the fields below. All fields marked with a red asterisk are required.

Please enable JavaScript in your browser to complete this form.

- Step 1 of 7

Scholar Enrollment Application

Scholar Information

Scholar Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Gender *

Male
Female
Prefer not to say

Scholar's Date of Birth *

Scholar's Aage *

Social Security Number

Parent/Guardian Name #1 *

First

Last

Parent/Guardian #1 Phone Number *

ex. 901-555-5555

Parent/Guardian #1 Cell Number

ex. 901-555-5555

Parent/Guardian #1 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Parent/Guardian #1 Work Number

ex. 901-555-5555

Parent/Guardian #1 Email Address *

Description of relationship

Parent/Guardian Name #2 *

First

Last

Parent/Guardian #2 Phone Number *

ex. 901-555-5555

Parent/Guardian #2 Cell Number

ex. 901-555-5555

Parent/Guardian #2 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Parent/Guardian #2 Work Number

ex. 901-555-5555

Parent/Guardian #2 Email Address *

Description of relationship

Additional Information

How did you hear about MCP?

Friend/Family
Online
Other

Other

What grade will the student be entering in the 2024-2025 school year? *

Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade

Did your scholar attend Pre-K in 2023 - 2024?

Yes
No
Not Applicable

What school is your scholar transferring from?

(Example: Shaw Elementary Memphis, Tennessee; leave field blank if they are beginning Kindergarten)

Does the student currently receive Special Education services under an Individualized Education Plan (IEP)? *

Yes
No
Other

Other

Does the student currently receive Special Education services under a 504 Plan? *

Yes
No
Other

Other

How will your scholar be picked up from school? *

Car rider
Walk with family member
Daycare rider

Special Contacts

Emergency Contact #1 Name *

First

Last

Please list a person we can contact in case of an emergency if a parent/guardian cannot be reached. A contact person would be someone who lives in the neighborhood or is otherwise readily available. By listing this person you are also authorizing them to pick up your scholar from school in the event of an emergency.

Emergency Contact #1 Number *

Emergency Contact #1 Relationship *

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Description of relationship

Emergency Contact #2 Name *

First

Last

Emergency Contact #2 Number *

Emergency Contact #2 Relationship *

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Description of relationship

Child Pickup Authorization #1 Name

First

Last

This individual has my permission to pick up my child from school. Any adult picking up a child must show their identification. Only list a name that is NOT a parent, guardian, or emergency contact listed above. Parents, guardians, and emergency contacts will be granted authorization to pick up the child.

Child Pickup Authorization #1 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Child Pickup Authorization #1 Number

Description of relationship

Child Pickup Authorization #2 Name

First

Last

Child Pickup Authorization #2 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Child Pickup Authorization #2 Number

Description of relationship

Child Pickup Authorization #3 Name

First

Last

Child Pickup Authorization #3 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Child Pickup Authorization #3 Number

Description of relationship

Child Pickup Authorization #4 Name

First

Last

Child Pickup Authorization #4 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Child Pickup Authorization #4 Number

Description of relationship

Child Pickup Authorization #5 Name

First

Last

Child Pickup Authorization #5 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Child Pickup Authorization #5 Number

Description of relationship

Child Pickup Authorization #6 Name

First

Last

Child Pickup Authorization #6 Relationship

Mom
Dad
Grandmother
Grandfather
Aunt
Uncle
Other

Child Pickup Authorization #6 Number

Description of relationship

Special Remarks or Concerns

i.e. court orders, daycares, after school pickup alternatives

Medical History

Pediatrician Name

First

Last

Pediatrician Number

Pediatrician Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Company Name

Insurance Policy Holder

First

Last

Insurance Policy Number

Insurance Group Number

Medication Allergies

Does your scholar have an Epi Pen?

Health Conditions

Diabetes
Asthma
Sickle Cell
Heart Promblems
ADHD/ADD
Hemophilia
Seizures
Eye Problems
Allergies
Speech Difficulties
Hearing Difficulties
Kidney Problems
Other

Please check the box if your scholar has any of the following health conditions below. If it is not listed please select "Other" and type in the health condition

Other Description

Medical Emergency Authorization

THIS HEREBY AUTHORIZES MEMPHIS COLLEGE PREPARATORY ELEMENTARY SCHOOL AND ITS STAFF TO ACT ON MY/OUR BEHALF WITH RESPECT TO ANY REQUIRED MEDICAL TREATMENT DECISIONS AND CONSENTS UNTIL SUCH TIME AS I/WE ARE ABLE TO PROVIDE THESE ITEMS. NOTICE IS HEREBY GIVEN TO ANY QUALIFIED MEDICAL PERSONNEL THAT THIS AUTHORIZATION IS CURRENTLY IN EFFECT, AND SUCH PERSONNEL ARE DIRECTED TO ACT UPON SUCH AUTHORIZATION WITHOUT DELAY.

I Hereby acknowledge: I/we may not be available to provide consent for medical treatment in the event that our child becomes sick or is injured during participation in a school authorized activity. If I/we are not available for such consent, it is my/our desire to have the best available medical treatment for my/our child. ___________________ I/We agree to assume financial responsibility for all expenses and bills incurred in any emergency requiring medical attention. *

PHOTO/VIDEO/MEDIA/STUDENT WORK RELEASE FORM

There are several times during the school year when the news media or school personnel may want to interview, videotape and/or photograph some of the great work happening at Memphis College Prep. Footage may highlight a specific event, body of work, or a successful classroom and feature the faces or work of our MCP scholars. This material may appear on the school’s website, social media or training materials. We value your child’s participation, and ask for your permission to include him or her. I understand that I agree to participate without financial compensation, and I understand that this releases the school/photographer/interviewer from any future claims, as well as from any liability, arising from the use of the said photograph/interview/video.

I give my permission to have my child interviewed, photographed, and videotaped by Memphis College Prep staff, news media or educational researchers. Photos, footage or work, may be used by the school on websites, social media and/or other printed materials.

Household Information Survey

Student's #1 Legal Name *

First

Last

Student's #1 School Name *

Student's #1 Date of Birth *

Student's #1 Grade *

Student's #2 Legal Name

First

Last

Student's #2 School Name

Student's #2 Date of Birth

Student's #2 Grade

Student's #3 Legal Name

First

Last

Student's #3 School Name

Student's #3 Date of Birth

Student's #3 Grade

Student's #4 Legal Name

First

Last

Student's #4 School Name

Student's #4 Date of Birth

Student's #4 Grade

Student's #5 Legal Name

First

Last

Student's #5 School Name

Student's #5 Date of Birth

Student's #5 Grade

Student's #6 Legal Name

First

Last

Student's #6 School Name

Student's #6 Date of Birth

Student's #6 Grade

Total Number of people living in Household?

Please check the box below that represents your Annual Gross Income

Less than $21,978
Between $21,978 and $29,637
Between $29,637 and $37,296
Between $37,296 and $44,955
Between $44,955 and $52,614
Between $52,614 and $60,273
Between $60,273 and $67,951
Between $67,951 and $75,647
Between $75,647 and $83,343
Between $83,343 and $91,039
Between $91,039 and $98,735
Between $98,735 and $106,431
Over $106,431

Write your first and last name if certify(promise) that all the information on this survey is true and that all income is reported. I understand that the school will receive federal funding based on the information provided.

First

Last

Tennessee Parent Occupational Survey

In order to better serve your child, our school district want to identify students who may qualify to receive additional educational services, such as tutoring, schools supplies, free or reduced-price linc, summer camps and other services. The information provided below will be kept confidential. Please answer the following questions.

Have you or an immediate family member performed any of the jobs listed below temporarily or seasonally, in any part of the United States, in the past three years?

Agriculture/Field Work (planting, picking, sorting crops, irrigation)
Processing & Packaging (fruit, vegetables, chicken , eggs, pork, beef)
Dairy/Cattle Raising (feeding, milking, rounding up)
Nursery/Greenhouse (planing, potting,pruning, watering, harvesting)
Forestry (soil preparation, planting, cutting trees, landscaping not inlcuded)
Commercial Fishing & Processing (catching, sorting, packing, transporting)

If you selected yes to any of the selections above, how many total months did you work?

In the past three years, has your family moved to another state, city, school district, and or county? *

Please provide how long you have resided at your current residence in Years, Months and Weeks

Primary Home Language Identification Form

The native/home language of each student must be recorded in his/her permanent record. Please answer the following questions about your child's language background

What was the first language this child learned to speak? *

English
Spanish
Other

Other Language *

What language does this child speak most often outside of school?

English
Spanish
Other

Other Language

What language do people usually speak in this child's home?

English
Spanish
Other

Other Language

Was this child born in the United States? *

What is this child Country of birth? *

Date entered United States? *

Date entered U.S. schools? *

Does your child have Refugee Status? *

This section is to be completed only for students who answered questions 1-3 with a language other than English.

In what language do you want notices sent to you from the school?

English
Spanish
Other

Other Language

LAU Category of student?

Category A - speaks only the language other than English
Category B - speaks mostly the language other than English
Category C - speaks English and the other language equally well
Category D - speaks mostly English
Category E - speaks only English

SCHOLARS

STAFF

AFTER SCHOOL PROGRAMS

YEARS ESTABLISHED

Get in touch

Location: 1500 Dunn Avenue, Memphis, TN 38106

Telephone: 901-620-6475

Email: support@memphiscollegeprep.org

School Hours: Monday – Friday: 7:45 AM – 3:45 PM