2023-2024 New Student Enrollment Application

Student's Legal Name:*

First

Middle

Last

Grade Entering:*

Previous School Attended *

Physical Address:*

Street Address Line City State Postal / Zip Code

Mailing Address:*

Street Address Line City State Postal / Zip Code

Student's Birth Date:*

day

month

year

Gender of Student:*

Male

Female

Other

Birth Status:*

Single

Twin

Triplet+

Primary Phone Number:*

County of residence:*

Are you a military family?*

Yes

Is English the primary language spoken in your home?*

Yes

If no, what is the primary language spoken?

Race- (Check all that apply) What do you consider your student's race?*

American Indian/Alaskan Native

Black/African American

Native Hawaiian/Pacific Islander

Asian American

Hispanic/Latino

White/Caucasian

Other

Special Education Please bring a copy of IEP. Did your student receive special education services at a previous school? *

Yes

(If yes, please indicate what types received)

Special Education classes

Speech

OT/PT

Social Work

504 Plan

Parent/Guardian 1:*

Custodial

Non-Custodial

Name:*

First

Last

Relationship to Student: *

Date of Birth:*

day

month

year

Email Address:*

Main Phone:*

Employer:*

Work Phone:

Parent/Guardian 2:

Custodial

Non-Custodial

Name:

First

Last

Relationship to Student:

Date of Birth:

day

month

year

Email Address:

Main Phone:

Employer:

Work Phone:

Secondary/Stepparent 1:

Custodial

Non-Custodial

Name:

First

Last

Relationship to Student:

Date of Birth :

day

month

year

Email Address:

Main Phone:

Employer:

Work Phone:

Secondary/Stepparent 2:

Custodial

Non-Custodial

Name:

First

Last

Relationship to Student:

Date of Birth:

day

month

year

Email Address:

Main Phone:

Employer:

Work Phone:

Has your child ever been suspended from school?*

Yes

If yes, why?

Has your child ever been expelled from school?*

Yes

If yes, why?

Where is the student currently living? (Please check one box, if one of the following boxes are checked the school may be required to fill out a McKinney-Vento referral)

In a one family dwelling

In a shelter

With family/friends (with parent)

In a car/garage

In a hotel/motel

Living with another family

At a campground

Homeless

Other:

Emergency Contact 1*

First

Last

Relationship*

Phone 1*

Phone 2

Emergency Contact 2

First

Last

Relationship

Phone 1

Phone 2

Emergency Contact 3

First

Last

Relationship

Phone 1

Phone 2

Does your student have any allergies or medical problems that the school should be aware of? *

Will your student need bussing?*

Yes

Which animal route best suits your needs? (routes are available online; subject to change)

Elephant

Tiger

Pig

Lion

Monkey

Chicken

Penguin

Deer

Dog

Bear

Camel

Please have transportation contact me to discuss routes

Parental Statement - By signing, I am confirming that the information given is true to the best of my knowledge. Failure to report accurate information may result in your student being withdrawn from the Academy. I agree to support the mission, vision, and policies of Charlton Heston Academy. By signing this I understand that there is a virtual learning platform available and virtual learning may be utilized as deemed necessary by administration. *

First

Last

I authorize Charlton Heston Academy to release my student's immunization record to the Michigan Department of Health and Human Services and Local Health Department. I understand this information will be used to improve the quality and timeliness of immunization services and to help schools comply with Michigan Law. This includes any immunization information and limited personally identifiable information from the school.

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Last

Immunizations are an important part of keeping our students healthy. Schools and State and Local health departments must monitor immunization levels to ensure that all communities are protected from potentially life-threatening diseases and, if necessary, respond promptly to an emerging public health threat. It is important that disease threats be minimized through the monitoring of students being immunized. Sharing immunization and personally identifiable information including the student’s name, Date of Birth, gender, and address with local and state health departments will help to keep your student safe from vaccine preventable diseases. The Family Educational Rights and Privacy Act (FERPA), 20 U.S.C. § 1232g, requires written parental consent before personally identifiable information from your student's education records is disclosed to the health department. If your student is 18 or over, they are an “eligible student” and must provide consent for disclosure of information from his or her education records. You may withdraw your consent to share this information in writing at any time.

By signing, you agree to reading the statement above.

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Last

2023-2024 New Student Enrollment Application

Authorized by Lake Superior State University

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