LifeWise Student Enrollment Permission Form
Custom Header
<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 during the day on a schedule that fits the public school classroom rotation</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/wetzelwv" target="_blank">lifewise.org/wetzelwv</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?
Please select...
Yes
No
Ask for Classroom Teacher?
Please select...
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
Please select...
Male
Female
School Year
Please select...
2024-2025
School
Grade
Grade of homeschooled student
Please select...
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Classroom Teacher
Shirt size
Please select...
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?
Please select...
Yes
No
Relationship to student
Are there any custody arrangements or no contact orders we should be aware of?
Please select...
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?
Please select...
Yes
No
Street Address
City
State
Zip Code
Additional Information
Additional email address for classroom communications
Does your student have any learning, behavioral or emotional needs of which we should be aware?
Please select...
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?
Please select...
Yes
No
Please list your student's health concerns/food allergies:
Does your student take any prescribed medications?
Please select...
Yes
No
Prescribed medications
Does your student have any medication allergies?
Please select...
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?
Please select...
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.
Please select...
Yes
No
Do you agree with the above statement?
Please select...
Yes
No
Do you agree with the above statement?
Please select...
Yes
No
Do you agree with the above statement?
Please select...
Yes
No
Do you agree with the above statement?
Please select...
Yes
No
Do you agree with the above statement?
Please select...
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
Custom Footer
LifeWise Program ID
Director Email
School Year One Option
School Year Two Options
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.