Re-Enrollment 26-27 - Legacy Academy

2026-2027 Re-enrollment Application (1)

Student Name (as it appears on birth certificate)(Required)

First Last

Parent/Guardian Name

First Last

Relationship to student:

Have you moved in the last six months? If Yes, Proof of address required: (must be within 30 days)

Max. file size: 1 GB.

Does your child need transportation?

If yes, please complete the transportation request form with the school office.

Yes

Emergency Contact and Authorization to release for Pick up: (Must be someone other than the residential parent/guardian) First Emergency Contact:

First Last

Phone

Second Emergency Contact. Name:

First Last

Phone

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

1. My child will be returning for 2026-27 school year

2. 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 with drawn from Legacy Academy of Excellence.

By signing below, I acknowledge and understand all of the above. Parent/Guardian Print:(Required)

Signature

Date

EMERGENCY INFORMATION CARD

Student Name

First Last

Medicaid Number

Social Security Number

Phone

School Attended

The following is required by section 3313.712 of the Ohio Revised Code. EMERGENCY MEDICAL AUTHORIZATION Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while Under school authority, when parents or guardians cannot be reached. PART I OR PART II MUST BE COMPLETED ALL BLANKS MUST BE COMPLETED

PART I (TO GRANT CONSENT) In the event reasonable attempts to contact me at (a)_________________ (phone) or (b)___________________(other parent) at (c)________________ (phone) have been unsuccessful, I HEREBY GIVE MY CONSENT for (1) the administration of any treatment deemed necessary by (preferred physician) Dr. (d)______________________________ at (e)___________________(phone), or (preferred dentist) Dr. at (f)_______________ (g)___________________(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: (h)________________________________________________________________________________________ (please enter your answers by entering the coordinating letter to each of your answers)

Signature

Date

DO NOT COMPLETE PART II IF YOU COMPLETED PART I

PART II (REFUSAL TO GRANTS 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

2026-2027 Re-enrollment Application (1)

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

EMERGENCY INFORMATION CARD

DO NOT COMPLETE PART II IF YOU COMPLETED PART I

PART II (REFUSAL TO GRANTS CONSENT)

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