2025-2026 Enrollment Application

Parent/Guardian 1:*

Custodial

Non-Custodial

Name:*

First

Last

Relationship to Student: *

Email Address:*

Main Phone:*

Employer:*

Work Phone:

Parent/Guardian 2:

Custodial

Non-Custodial

Name:

First

Last

Relationship to Student:

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?

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

According to Michigan Law, if a child residing in Michigan is not five years of age on September 1, 2020, but will be five years of age not later than December 1, 2020, the parent or legal guardian of that child may enroll the child in Kindergarten for the 2025-2026 school year if the parent or legal guardian notifies the school district in writing that he or she intends to enroll the child in Kindergarten. A school district that receives this written notification may make a recommendation to the parent or legal guardian as to whether the child is not ready to enroll in Kindergarten due to the child's age or other factors. Regardless of the district recommendation, the parent or legal guardian retains the sole discretion to determine whether or not to enroll the child in Kindergarten if the student is five years of age not later than December 1, 2025.

Acknowledged

Student Name:

First

Last

Date of Birth

day

month

year

Evidence of School readiness (provided by parent) (1)

Evidence of School readiness (2)

Evidence of School readiness (3)

Evidence of School readiness (4)

Parent/Guardian's Printed Name

First

Last

Parent/Guardian's Signature

Date

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even what seems to be a mild bump or blow to the head can be serious. If a child reports one or more symptoms of concussion listed below after a bump, blow, or jolt to the head or body, she/he should be kept out of school the day of the injury and until a health care professional, experinced in evaluating for concussion says they are symptom-free and may return to school. Symptoms: Appears dazed or confused, headache or "preassure" in head, confused, nausea or vomiting, forgetful, balance problems or dizziness, clumsy, sensitivity to light, answers questions slowly, sensitive to noise, loses consciousness, feeling sluggish/hazy/foggy/ or groggy, shows mood/behavior/ or personality changes, concentration or memory problems, can't recall events prior to the hit or fall, confusion, can't recall events after the hit or fall, not "feeling right" or "feeling down" *

Acknowledged

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. Concussion affects people differently. While most recover quickly and fully, some will have symptoms that last for days or even weeks. A more serious concussion can last for months or longer. Sign below to indicate that you have been made ware of the dangers and warning signs of concussions as well as being informed of the acceptable use policy.*

Date*

Student's Name

First

Last

Consent to Release Student records

Student Name:

First

Last

Student Name:

First

Last

Student Name:

First

Last

Student Name:

First

Last

Student Start Date*

School last attended *

School Phone

School Fax

School Email

Please send all educational records for the student(s) listed above. This release also requests an immediate email attachment to office@charltonhestonacademy.com of the most recent IEP, 504, and discipline report, if applicable. *

Acknowleged

Parent/Guardian Signature*

Authorized by Lake Superior State University

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