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

Student Information

First Name

Last Name

Birth Date

Gender

School Year

School

Grade

Grade of homeschooled student

Classroom Teacher

Shirt size

Parent/Guardian Information

First Name

Last Name

Phone Number

Street Address

City

State

Zip Code

Are you a parent/legal guardian of this student?

Relationship to student

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

First Name

Last Name

Relationship to student

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 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

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

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.

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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LifeWise Program ID

Director Email

School Year One Option

School Year Two Options