LifeWise Student Enrollment Permission Form

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Ask for gender?

Ask for Classroom Teacher?

Allow option to add additional parent information?

Ask T-Shirt Question?

Ask for Additional Email Address?

Ask Student Needs Question?

Yes/No Question 1?

Yes/No Question 2?

Yes/No Question 3?

Yes/No Question 4?

Yes/No Question 5?

Text Response Question 1?

Text Response Question 2?

Text Response Question 3?

LifeWise Program Name

2025-2026 Enrollment open?

2024-2025 Enrollment Closed?

Student Information

Student First Name

Student Last Name

Birth Date

Please select a date with the calendar

Gender

School Year

School

Grade

Classroom Teacher

Shirt size

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Street Address

City

State

Zip Code

Are you the custodial parent/legal guardian of this student?

Relationship to student (if not custodial parent/legal guardian)

Are there any custody arrangements or no contact orders we should be aware of?

Please explain the custody arrangements for this Student.

Add another parent/guardian

Additional Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to student (if not custodial parent/legal guardian)

Phone

Do you have the same address as the parent/guardian above?

Street Address

City

State

Zip Code

Additional Information

Additional (parent/guardian) email address for classroom communications

Does your student have any learning, behavioral or emotional needs of which we should be aware?

Please explain your student's needs:

Does your student have any medical conditions we should be aware of?

Describe Diagnosed Medical Conditions

Signs and Symptoms of Medical Emergency (list specific symptoms to watch for)

Emergency Action Steps (When symptoms escalate - Include steps like administering medication, the student self-administering, calling 911, contacting parents, etc. )

A member of the Program team will reach out to you to review and confirm these important details.

Does your student have any allergies we should be aware of?

Allergens (Food, medications, bee stings, etc.)

Typical Reaction

Emergency Treatment Instructions (e.g., antihistamine, epinephrine (Epi-Pen), call 911)

Does your student need emergency medication on site at LifeWise?

Do you consent to the photography or video of your student while in LifeWise, for promotional purposes?

Do you consent to the disclosure of personally identifiable information (as defined in FERPA) including medical information to LifeWise personnel in the event of a medical emergency or for reasons determined by the school district as appropriate.

Do you agree with the above statement?

Type your answer here

Yes, I choose to allow my student to attend LifeWise Academy classes.

I understand that this form will not be processed until I verify my email address in the next step.

Signature

Your Full Name

Signature

Do you accept this signature as your own?

Yes

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Policies are available at lifewise.org/parentinfo.

The school district and its employees shall not incur any liability as a result of any injury sustained by the student related to participation in the LifeWise program.

LifeWise Program ID

Director Email

School Year One Option

Program State