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Dream Academy Registration Application

Student Information

First Name

Middle Name

Last Name

Date of Birth

Gender

Is your student currently on an IEP?

Yes

Allergies, special needs, comforting items. [If none, put N/A.]

Current medications. [If none, put N/A.]

Race

Ethnicity

Grade (2025-2026 School Year)

Previous School Information

Last School Attended

Years at School

Primary Parent/Guardian [1]

First Name

Middle Name

Last Name

Relationship to the student

Primary Language

Home Address

Street Address

City

State

Zip Code

Mobile phone

Home phone

Work phone

Place of Employment

Address of Employment

Street Address

City

State

Zip Code

Primary Parent/Guardian [2]

First Name

Middle Name

Last Name

Relationship to the student

Primary Language

Home Address

Street Address

City

State

Zip Code

Mobile phone

Home phone

Work phone

Place of Employment

Address of Employment

Street Address

City

State

Zip Code

Why do you want to enroll your child(ren) at the Dubuque Dream Center Academy?

Separation, Divorce, Custody

If there is a separation, divorce, or custody issue that we should be aware of, please explain. [Please also provide all necessary legal documentation.]

Emergency Contacts

Please list at least one(1) emergency contact.

Emergency Contact [1]

First Name

Middle Name

Last Name

Relationship to the student

Mobile phone

Home phone

Work phone

Emergency Contact [2]

Some description about this section

First Name

Middle Name

Last Name

Relationship to the student

Mobile phone

Home phone

Work phone

Medical Information

CHILD'S DOCTOR'S NAME

Phone

Location

Street Address

City

State

Zip Code

PREFERRED HOSPITAL

Hospital Phone

Location

Street Address

City

State

Zip Code

CHILD'S DENTIST'S NAME

Phone

Location

Street Address

City

State

Zip Code

AUTHORIZATION

This form allows parents and guardians to authorize the provision of emergency treatment for the child(ren) named who becomes ill or injured while under program authority when parents or guardians cannot be reached. In the event reasonable attempts to contact have been unsuccessful, I hereby give consent for the administration of any treatment deemed necessary by the doctor or dentist listed above, or if unavailable, another licensed physician or dentist.

I agree to pay all costs and fees as secured or authorized under this consent.

PARENT/GUARDIAN SIGNATURE (your full name)

DATE

PARENT/GUARDIAN SIGNATURE (your full name)

DATE

The Dubuque Dream Center Academy ...

... prohibits discrimination against its families, employees, or applicants for employment on the basis of race, color, national origin, age, disability, sex, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status.

Radio Field

Yes

Student Information

Previous School Information

Primary Parent/Guardian [1]

Primary Parent/Guardian [2]

Separation, Divorce, Custody

Emergency Contacts

Emergency Contact [1]

Emergency Contact [2]

Medical Information

AUTHORIZATION

The Dubuque Dream Center Academy ...