Re-Enrollment 25/26 – Legacy Academy

2025-26 Re-Enrollment Application

Legacy Academy 25/26

Student Name (as it appears on birth certificate)

First Last

Student Date of Birth:

Student Gender:

PARENT INFORMATION

Parent/Guardian First and Last Name:

First Last

Relationship to Student:

Parents Marital Status:

Child Lives with:

Email Address:

Phone

Work Phone:

Parent/Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Proof of Address:

Max. file size: 100 MB.

(Must be updated annually) Deed, mortgage, lease, current homeowners or renters insurance declaration page, current real property tax bill, utility bill, receipt of utility installation, bank statement, paycheck or pay stub issued to the parent, notification from Social Security and/or Jobs and Family Services, Notarized affirmation from parents of current resident address. (must be current or dated within 30 days of enrollment)

Does your child need transportation?:

Yes

If yes please complete the transportation request online with the Columbus City Schools. (https://www.ccsoh.us/Page/4818) 614-365-5074

Emergency Contact Information: (Must be someone other than the residential parent/guardian) First contact:

First Last

Phone

Second Emergency contact:

First Last

Phone

Authorization to Release

Person 1 First Name Last

Who has authorization to pick up the student from school? Please provide the full name of each individual:

Name

Person 2 First Name Last

***NOTE: Any person picking up students will be required to show state issued picture identification***

Please initial below

1. My child will be returning for the 2025-2026 school year.

2. I understand in order for my child to remain a student at Legacy Academy of Excellence; he/she must must attend the first day of school.

3. I understand that if my child fails to attend 72 hours. A student who fails to participate in seventy two (72) consecutive hours of learning opportunities offered, unless the student’s absence is excused will be automatically withdrawn from Legacy Academy of Excellence.

4. I understand my child is prohibited from attending another school while attending Legacy Academy of Excellence._______

By signing below, I acknowledge and understand all of the below.

Parent/Guardian Print

First Last

Signature

Date

Received by:

First Last

Students Name

First Last

Medicaid Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Social Security Number

Phone

School Attended

The following is required by section 3313.712 of the Ohio Revised Code.

PART I (TO GRANT CONSENT) In the event reasonable attempts to contact me at (phone)

or (other parent) at

(phone).

I HEREBY GIVE MY CONSENT for (1) the administration of any treatment deemed necessary by (preferred physician) Dr.

at (Phone)

or (preferred dentist) Dr

at (phone)

Phone

or in the event the DESIGNATED preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to Nationwide Children’s Hospital (preferred hospital) or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed.

FACTS CONCERNING THE CHILD’S MEDICAL HISTORY INCLUDING ALLERGIES, MEDICATIONS BEING TAKEN, AND ANY PHYSICAL IMPAIRMENTS to which a physician should be alerted:

Please sign above

Date

DO NOT COMPLETE PART II IF YOU COMPLETED PART I PART II (REFUSAL TO GRANT CONSENT) I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to TAKE NO ACTION OR TO:

Signature

Date

Handbook Acknowledgement Page I have received an electronic copy of the student Handbook. I have been made aware of all policies and procedures.

Parent/Guardian Signature

Date

Consent Media Release

Student Name

First Last

Grade

School: Legacy Academy of Excellence I hereby give Legacy Academy of Excellence the right and permission to publish, use photographs or video, and/or audio recordings of my child, a student enrolled in Legacy Academy of Excellence. I understand that such reproductions could be used to publicize or promote the school system, and/or my child’s school through its own media productions (district Website, social media, printed and/or online brochures, reports, promotional videos, etc.) or through the commercial media (television, radio, Internet or print). I waive any right to inspect and/or approve the publication of the product and do release Legacy Academy of Excellence from any liability by virtue of distortion by processing. I further agree that these items may be used for publication, broadcast or reproduction without limitation or reservation or any fee.

I DO give my consent or permission to publish, use photographs or video, and/or audio recordings of my child, a student enrolled in Legacy Academy of Excellence.

I DO NOT give my consent or permission to publish, use photographs or video, and/or audio recordings of my child, a student enrolled in Legacy Academy of Excellence.

Parent/Guardian Signature

Parent/Guardian Name

First Last

Date