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 Date of Birth (mm/dd/yyyy): *

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: *

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?

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? *

Is your high school child interested in Career and Technical Education (CTE) courses? CHA is currently offering the following CTE courses; Teacher Cadet, Automotive Technology, Construction Trades, Public Safety, Cosmetology, Information Technology and Gaming, and Welding.)*

Yes

Which of our CTE courses is your student interested in pursuing?

Teacher Cadet

Automotive Technology

Construction Trades

Public Safety

Cosmetology

Information Technology and Gaming

Industrial Maintenance Technology

Is your high school child interested in college classes*

Yes

Is your child interested in online learning (Approval from the Superintendent is required)*

Yes

Will your student need bussing?*

Yes

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

Flamingo

Tiger

Turtle

Lion

Monkey

Eagle

Penguin

Deer

Owl

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

According to Michigan Law, if a child residing in Michigan is not five years of age on September 1, 2026, but will be five years of age not later than December 1, 2026, the parent or legal guardian of that child may enroll the child in Kindergarten for the 2026-2027 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, 2026.

Acknowledged

Student Name:

First

Last

Date of Birth

day

month

year

Verification of Age

Birth Certificate

Court Record

Government Record

Citizenship Paper

Hospital Record

Other

If other

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

Directory information consists of a student’s name, participation in officially recognized activities and sports, height, and weight (if member of an athletic team), awards received, honor rolls, scholarships, photographs or videos, and grade. The Board designates school-assigned e-mail accounts as "directory information" for the limited purpose of facilitating students’ registration for access to various online educational services, including mobile applications/apps that the student will use for educational purposes, and for inclusion in internal e-mail address books. School-assigned e-mail accounts shall not be released as directory information beyond this/these limited purposes and to any person or entity but the specific online educational service provider and internal users of the District's Education Technology.

• School Yearbook

• Athletic Programs

• Academic Honor Roll/Awards Programs

• Graduation Program

• Student of the Week/Month

• National Honor Society Programs

• Interviews, photographs, or videos for use in school/district publications

• College Recruitment

PHOTO, PRESS, AUDIO, AND ELECTRONIC MEDIA RELEASE FOR MINORS *

Permission IS granted to use the directory information of my child, given the guidelines stated above for the school year.

Permission IS NOT granted to use the directory information of my child, given the guidelines stated above for the school year.

CHOOSE ONE (High School Students Only):

Permission IS granted to release information to the military.

Permission IS NOT release information to the military.

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.

First

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.

First

Last

I have read and understand the Charlton Heston Academy Google Workspace. The policy can be found on the www.charltonhestonacademy.com website.*

Permission IS granted

Permission IS NOT granted.

I have read the School Handbook, which can be found online at www.charltonhestonacadey.com, and have made sure my child understands the policies and rules as stated in the document.*

I agree to the handbook policy and rules

I do NOT agree to the handbook policy and rules

I authorize Charlton Heston Academy to enroll my child in virtual course(s) if necessary.*

I agree to virtual courses

I do NOT agree to virtual courses

Signature of Parent/Guardian*

Chromebook User and Parent Agreement

To use school technology, students and their parents must agree to the following terms:

Students will use technology only for school-related purposes.
Students will not purposely damage or otherwise deface school technology.
Students will not take school technology out of the room it is assigned to without explicit permission from their teacher.
If damage occurs, students and their parents may be charged for repair as outlined below:

Screen damage: $20
Keyboard damage: $35
Backplate/Faceplate damage: $20
Removal of CHA labeling: $5
Writing/carving/defacement: $25
Charger: $25
Stolen, lost, or otherwise unrepairable: $320

(Chromebook Agreement) Student Name*

(Chromebook Agreement) Date:*

(Chromebook Agreement) Student Signature*

(Chromebook Agreement) Parent/Guardian Signature*

2026-2027 Enrollment Application

Chromebook User and Parent Agreement

Authorized by Lake Superior State University

Management Company

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