Charlton Heston Academy New Enrollment 2021-2022 PLEASE CONFIRM YOU ARE APPLYING FOR CHARLTON HESTON ACADEMY *AGREE YOUR CHILD MUST BE 5 YEARS OF AGE BY SEPTEMBER 1ST, 2021 TO ENROLL IN KINDERGARTEN. WAIVERS WILL ALLOW STUDENTS TO ENROLL IF AGE 5 BY DECEMBER 1ST, 2021. YOUR CHILD MUST BE 4 YEARS OF AGE BY SEPTEMBER 1ST, 2021 TO ENROLL IN PRE-K*Please Click If You Have Acknowledged This Statement Grade Entering In September 202112th11th10th9th8th7th6th5th4th3rd2nd1stKindergartenPre-K/Childcare Military Family?*YesNo Please Type Name of Previous School * Ethnic Background*African American American IndianHispanicCaucasian LatinoOther Other: Student Name*FirstMiddleLast Date of Birth * Current Age* Gender *MaleFemale Student Address* Street Address Line City State Postal / Zip Code Does your child receive school-based special services, i.e special education? If "yes," please check all that apply: *Speech Therapy Occupational Therapy Physical TherapySocial Work Academic Support NoOther: Other: Family Information - Parent/Guardian Name*FirstLastMiddle Address* Street Address Line City State Postal / Zip Code Phone* Email Family Information - 2nd Parent/Guardian NameFirstLastMiddle Address Street Address Line City State Postal / Zip Code Phone(1) Email(1) Emergency Contact's Name*FirstLast Phone #* Emergency Contact's Name #2FirstLast Phone #2* 1. Siblings Name:FirstLast 2021-2022 Grade Level12th11th10th9th8th7th6th5th4th3rd2nd1stKindergartenPre-K/Daycare Date of Birth 2. Siblings Name:FirstLast 2021-2022 Grade Level12th11th10th9th8th7th6th5th4th3rd2nd1stKindergartenPre-K/Daycare Date of Birth Please confirm by clicking yes, that you are applying your child/children to Charlton Heston Academy*Yes Type your name(s) (first and last of parent(s)/guardian(s)) if you confirm that the information given is true to the best of your knowledge. You also agree failure to report information may result in your child being withdrawn from the Academy. To add, you agree to support the mission, vision, and policies of Charlton Heston Academy. * The Academy will follow-up with families to retrieve the following information: - Copy of certified birth certificate - Health appraisal (Kindergarten & Grade 6) - Certified copy of court appointed custodial papers (if applicable) -Up-to-date immunization record - Copy of valid identification - Copy of the student's last report card - All other applicable academic, medical, and/or other information - All questions can be directed to David Patterson, Superintendent at 989-632-3390 or at dpatterson@charltonhestonacademy.com. *CLICK IF YOU HAVE ACKNOWLEDGED THIS STATEMENT Student Name*FirstLast Date of Birth School Last Attended* School Phone* Grade Entering*SelectK1st2nd3rd4th5th6th7th8th9th10th11th12th This student is currently in good standing with the district and is not currently serving a long-term suspension or expulsion. By typing your name below, you are agreeing to the statement. *Consent for Disclosure of Personally Identifiable Information and Immunization Information to Local and State Health Departments Immunizations are an important part of keeping our children healthy. School, 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 keep your child safe from caring preventable diseases. The Family Educational Right and Privacy Act (FERPA), 20 U.S.C. and 1232g, requires written parental consent before personally identifiable information and immunization information from your child's education records is disclosed to the health department. If your child is 18 or over, he or she is an "eligible student" and must provide consent for disclosures of information from his or her education records. You may withdraw your consent to share this information in writing at any time. Students Name*FirstLast Date of Birth * I authorize Charlton Heston Academy to release my child's immunization record and personally identifiable information to the Michigan Department of health and Human Resources 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. (type your name below to digitally sign) * Date of Digital Signature *SubmitReset
