LifeWise Student Enrollment Permission Form
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<p>In addition to their regular classes, parents have the option of enrolling their children in LifeWise Academy.</p> <ul><li>LifeWise Academy is a non-denominational, Bible-based released time religious instruction program with emphasis on character education</li><li>Students attend classes one day a week during their lunch & recess time</li><li>Students will walk or travel by bus or van with chaperones to and from their LifeWise classes</li><li>For more details, visit <a href="https://lifewise.org/worthingtonoh" target="_blank">lifewise.org/worthingtonoh</a></li></ul> <p>Note: This permission slip will remain in effect as long as the child is enrolled with the local public school.</p>
Ask for gender?
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Yes
No
Ask for Classroom Teacher?
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Yes
No
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
Student Information
First Name
Last Name
Birth Date
Gender
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Male
Female
School Year
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2024-2025
School
Grade
Grade of homeschooled student
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K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Classroom Teacher
Shirt size
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Youth Small
Youth Medium
Youth Large
Adult Extra Small
Adult Small
Adult Medium
Adult Large
Adult Extra Large
Parent/Guardian Information
First Name
Last Name
Email
Phone Number
Street Address
City
State
Zip Code
Are you a parent/legal guardian of this student?
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Yes
No
Relationship to student
Are there any custody arrangements or no contact orders we should be aware of?
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Yes
No
Please explain the custody arrangements for this Student.
Add another parent/guardian
Additional Parent/Guardian Information
First Name
Last Name
Relationship to student
Email
Phone
Do you have the same address as the parent/guardian above?
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Yes
No
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?
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Yes
No
Please explain your student's needs:
Does your student have any health concerns or food allergies of which we should be aware of?
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Yes
No
Please list your student's health concerns/food allergies:
Does your student take any prescribed medications?
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Yes
No
Prescribed medications
Does your student have any medication allergies?
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Yes
No
Medication allergies
Signs & symptoms
Action plan
A member of the Program team will reach out to you to review and confirm these important details.
x
Preferred Physician name
Preferred Physician phone
Preferred Hospital name
Preferred Hospital address
Do you consent to the photography or video of your student while in LifeWise, for promotional purposes?
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Yes
No
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.
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Yes
No
Do you agree with the above statement?
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Yes
No
Do you agree with the above statement?
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Yes
No
Do you agree with the above statement?
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Yes
No
Do you agree with the above statement?
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Yes
No
Do you agree with the above statement?
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Yes
No
Type your answer here
Type your answer here
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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LifeWise Program ID
Director Email
School Year One Option
School Year Two Options
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