Academy Application 2021

LifeWise Academy Application 2021

STUDENT INFORMATION
Name *

First Name Middle Initial Last Name
Preferred name:
Address *

Street Address

Apartment or Unit Number

City State

Postal / Zip Code
Phone Number (Cell Phone) *

Area Code Phone Number
Phone Number (Home Phone)

Area Code Phone Number
Email *
Gender *
Age *
Date of Birth *

Month Day Year
Race/Ethnicity: *
Language spoken at home: *
Who does the applicant live with? *
Social Security Number:

SCHOOL INFORMATION
Name of school currently attending: *
Anticipated graduation year: *
Name of school counselor: *
Current GPA: *
Are you in the Free of Reduced Lunch Program? *

YES NO
IEP/Learning Disability/Special Education/Resource Room *

YES NO
If yes, please explain:
Have you ever been suspended from school? *

YES NO
If yes, please explain:
*PLEASE PROVIDE A COPY OF THE MOST RECENT REPORT CARD. IF YOU HAVE AN ELECTRONIC COPY, YOU MAY UPLOAD IT USING THE BUTTON BELOW

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STUDENT HEALTH INFORMATION
Do you have any health conditions or allergies? *

YES NO
If yes, please list conditions or allergies:
Do you take any medications? *

YES NO
If yes, please list medications:
Do you have any dietary or food restrictions? *

YES NO
If yes, please list restrictions:

SECOND PARENT/GUARDIAN/EMERGENCY CONTACT
Second Parent/Guardian Name

First Name Last Name
Date of Birth

Month Day Year
Relationship to child:
Relationship to Child:
Address

Street Address

Apartment or Unit Number

City State

Postal / Zip Code
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Email

RELEASE CLAUSE
The undersigned hereby releases and holds harmless LifeWise StL and any officers, employees or agents thereof, from any and all claims liabilities, or demands whatsoever arising out of the enrollment or participation in any program by the participant herein.
Signature of Parent/Guardian *

Clear
Date of Signature *

Month Day Year

EMERGENCY CLAUSE
In the event I cannot be reached in an emergency, I hereby give my persmission to employees of LifeWise StL to secure proper medical care for my child as deemed necessary. This permission extends from minor first-aid treatment to (under a doctor's orders) hospitalization, injections, anesthesia, urgery, and other medical procedures deemed necessary.
Signature of Parent/Guardian *

Clear
Date of signature *

Month Day Year
Name of Child's Primary Physician or Clinic *

First Name Last Name
Primary Physician/Clinic Phone Number

Area Code Phone Number
Name of Preferred Hospital:
Preferred Hospital Phone Number

Area Code Phone Number

CONSENTS
CONSENT TO RELEASE SCHOOL INFORMATION

I give my consent to school counselors, teachers, social workers, and all others working with my child to release records to LifeWise StL, including information on behavior at school, grades, transcripts, test scores, special education services, notification of suspensions, etc. I understand that all information given to LifeWise StL will be restricted and confidential.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year
CONSENT TO PARTICIPATE IN SURVEYS

I hereby grant permission for my child to participate in LifeWise StL surveys. Surveys are used to gather data about your child's experience, gain in knowledge and skills, demographics, and development of future programming.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year
BUS TICKET CONSENT

As an after-school program that serves students across the St. Louis Metro area, LifeWise Academy can provide Metro bus passes to students to get to and from LifeWise Academy. I hereby give LifeWise Academy permission to give my minor child St. Louis Metro bus passes to get to and/or from LifeWise Academy and/or events sponsored by LifeWise Academy. I understand that only LifeWise Academy scholars may use these bus passes, and they may only use them to get to and/or from LifeWise Academy and/or events sponsored by LifeWise Academy.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year
FIELD TRIPS CONSENT

Youth development program activities involve transportation to and from the destination. Some field trips may require a separate nominal fee. By signing below, I grant permission for my child to be transported to field trips during summer and academic year activities. My signature also acknowledges that I may be required to provide additional fees for specific field trips.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year
LEAVING LIFEWISE ACADEMY PREMISES CONSENT

I hereby give my persmission to my minor child to leave LifeWise Academy premises should they choose to for any reason. LifeWise Academy scholars must sign in when they arrive at LifeWise Academy and sign out when they leave. I understand that if my minor child decides to leave the LifeWise Academy building, neither LifeWise Academy nor LifeWise STL may be held responsible for their whereabouts.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year

RELEASES
MEDIA RELEASE

I hereby grant permission to record my child/ward's likeness and/or voice for use by television, films, radio, or printed media to further the aims of LifeWise StL in related campaigns and magazine articles, booklets, posters, and in other ways they may see fit.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year
ASSESSMENT/TESTING RELEASE

I hereby give permission for my child to participate in testing that will evaluate their literacy skills (such as fluency and comprehension). I understand that I have access to results of literacy assessments, and that results will help LifeWise StL determine if gains in literacy have occurred.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year
TRANSPORTATION RELEASE

I hereby give permission to LifeWise StL to transport my minor child in a motor vehicle driven by an authorized LifeWise StL staff member. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver. I understand participation in the identified event is not a requirement or a right for my child's participation in the program, and can be revoked based on poor behavior.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year
LOST, STOLEN, AND/OR DAMAGED POSSESSIONS

I have been hereby informed that my child should not bring valuable possessions (such as electronic devices) to LifeWise StL. I understand that LifeWise StL is NOT responsible for replacing any property that is lost, stolen, and/or damaged while attending programming.
Signature of Parent/Guardian

Clear
Date of signature

Month Day Year

FINAL SIGNATURE AND REQUIRED DOCUMENTS
Student Name *

First Name Last Name
Student Date of Birth *

Month Day Year
Signature of Parent/Guardian *

Clear
Date of signature

Month Day Year
THE FOLLOWING DOCUMENTS ARE REQUIRED FOR SCHOLAR STIPEND ELIGIBILITY. IF YOU HAVE ELECTRONIC COPIES OF THESE DOCUMENTS, YOU MAY UPLOAD THEM USING THE LINKS BELOW
- Picture ID (student ID, state-issued ID)
- Social Security Card OR Birth Certificate (to be photo-copied at LifeWise Academy)
- Federal W-4
- Missouri W-4
- I-9
Picture ID

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Social Security Card OR Birth Certificate

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Federal W-4

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Missouri W-4

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Cancel of
I-9

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LifeWise Academy Application 2021