LifeWise Student Enrollment Permission Slip

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Student Information

First Name

Last Name

Birth Date

Enrolling for 2023-2024?

School Year

School

Grade

Ask for Classroom Teacher?

Classroom Teacher

Ask T-Shirt Question?

Shirt Size

Parent/Guardian Information

First Name

Last Name

Phone Number

Street Address

City

State

Zip Code

Ask for Additional Email Address?

Additional Email Address for Classroom Communications

Additional Information

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

Ask Student Needs Question?

Please explain your student's needs:

Does your student have any health concerns or food allergies of which we should be aware of?

Please list your student's health concerns/food allergies:

Does your student take any prescribed medications?

Prescribed medications

Does your student have any medication allergies?

Medication allergies

Signs & symptoms

Action plan

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?

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.

Yes, I choose to allow my child to attend LifeWise Academy classes. I have read and fully understand the terms of the Release and Waiver and I am voluntarily giving up substantial legal rights, including the right to sue LifeWise Academy.

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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School Year ID

Director Email