Re-Enrollment Application for Columbus LAE

Re-Enrollment Form Columbus

Enrollment Columbus

Student Information

Student Name (as it appears on birth certificate)

First Last

Student Date of Birth

Student Gender

Parent Information

Parent/Guardian First and Last Name:

Relationship to Student:

Parent/Guardian please provide a current, state issued, photo identification. If someone other than mother/father is listed, please provide proof of custody paperwork (date and time-stamped by the court)

Parents Marital Status:

Child Lives with:

Phone

Work Phone

Address

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

Proof of Address:

(Must be updated annually.) Deed, mortgage, lease, current homeowners or renters insurance declarations page, current real property tax bill, utility bill, receipt of utility installation, bank statement, paycheck or pay stub issued to 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.)

ENROLLMENT APPLICATION

Student Information

Student Name

First Last

Student Date of Birth

City of Birth:

Last grade the student completed:

Proof of Age documentation provided (must be legible): Birth Certificate, Passport, Other

Max. file size: 100 MB.

Student Gender

Parent Information

Parent/Guardian Name

First Last

Relationship to Student:

Max. file size: 100 MB.

Parent Marital Status:

Child Lives with:

Email Address

Parent/Guardian active or former military: Yes or No if yes, please list status

Phone

Work Phone

Parent/Guardian Address

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

(Parent/Guardian will be responsible to provide the school with the proof of residency at time of enrollment, any time an enrolled student changes their residency or at the request of the school. Once a student is enrolled parent/guardian must provide the school with proof of residency annually).

Proof of Address provided:

Max. file size: 100 MB.

Deed, mortgage, lease, current homeowners or renters insurance declaration page, 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:

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

First Emergency Contact:

First Last

Phone

Second Emergency Contact:

First Last

Phone

Authorization to Release #1

First Last

Authorization to Release #2

First Last

Please Initial Below (1-4)

1. My child will be returning for the 2024-2025 school year.

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

3. I understand that if my child fails to attend 72 consecutive hours of learning opportunities offered, unless the students 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.

Section Break

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

Parent/Guardian Name (Print)

Parent/Guardian Signature

Date

Received by:

Date

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 (D: preferred physician) Dr.____________ at_(E: phone), or (F: preferred dentist) Dr. _ at_____________(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 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.

(A)

(B)

(C)

(D)

(E)

(F)

(G)

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

Signature of Parent Guardian

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, I wish the school authorities to TAKE NO ACTION or to:

Signature

Date

Handbook Acknowledgement

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.

Parent/Guardian Signature

Parent/Guardian Name

First Last

Date

Comments

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