Trinity AME Early Learning Center LLC
604 Lynhurst Drive SW, Atlanta, GA 30311
Phone: 404-696-3490
Rev. Charles Ramsey, Board Chairperson
Mr. Thomas Ford, ExecutiveDirector
Registration Packet
Student Name:_________________DOB:_____________
Enrollment Date:_______________________
Mother’s Name:_________________________________
Cell Phone:________________Work Phone:____________
Father’s Name:__________________________________
Cell Phone:________________Work Phone:____________
EMERGENCY MEDICAL AUTHORIZATION
Should (Child’s Name) ____________________________________ suffer an injury or illness
while in the care of Trinity AME Early Learning Center, LLC and the facility is unable to contact
me (us) immediately, it shall be authorized to secure such medical attention and care for the
child as may be necessary. I (We) shall assume responsibility for payment for services.
Parent/Guardian ______________________
Signature (Parent/Guardian): _____________________________________
Date: ___________________________
Facility Administrator : Thomas Ford
Signature:__________________________