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 may voluntarily opt to 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 information visit lifewise.org/aurorawestil</li></ul><p style="text-align: center;"><strong style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">This program is not sponsored, operated, or supervised by the local school district. Student participation is voluntary upon written permission of the parent/guardian. This permission form will remain in effect during the current school year the child is enrolled with the local public school. </strong></p>
Ask for gender?
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Ask for Classroom Teacher?
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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
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Gender
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Male
Female
School Year
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2024-2025
School Year
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2024-2025
2025-2026
School Year
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2025-2026
School
Grade
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
Parent/Guardian First Name
Parent/Guardian 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
Parent/Guardian
First Name
Parent/Guardian
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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No
Please list your student's health concerns/food allergies:
Does your student take any prescribed medications?
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No
Prescribed medications
Does your student have any medication allergies?
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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
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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No
I acknowledge that my child will be offered a bag lunch from District 129 on the day of their participation in LifeWise Academy instruction, or I may choose to send a lunch from home.
Do you agree with the above statement?
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No
I acknowledge that my child will not participate in recess on the day they attend LifeWise Academy.
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I acknowledge that our family is responsible for any missed instructional time resulting from my child's participation in LifeWise Academy during school hours.
Do you agree with the above statement?
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I acknowledge that my child will not be under the care, control, or supervision of District 129 when they are released to the below named contact(s) to travel to the LifeWise Academy class and during their participation in the LifeWise Academy class until their return to the Elementary School.
Do you agree with the above statement?
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Yes
No
For District 129 Use: Please provide the name and contact information of the people who will ensure your child's safe and timely travel to and from the elementary school during their LifeWise Academy participation. These individuals will be listed as an emergency contact in District 129's student information, for this limited purpose, for the current school year, or unless revoked by the parent. Contact Name: Christie Hart | Phone Number: 630-276-8723 Contact Name: Tori Mull | Phone Number: 630-659-7563 Contact Name: Rebecca Griffey | Phone Number: 630-564-7923 Contact Name: Jan Peterson | Phone Number: 630-885-1158
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
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