• LifeWise Academy Application 2021

    • STUDENT INFORMATION  
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    • SCHOOL INFORMATION  
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    • STUDENT HEALTH INFORMATION  
    • PARENT/GUARDIAN INFORMATION  
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    • Relationship to child: *

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    • Are you currently employed?
      If yes, what is the name of your employer?

    • Are you currently in school?
      If yes, where do you attend school?

    • SECOND PARENT/GUARDIAN/EMERGENCY CONTACT  
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    • Relationship to child:

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    • HOUSEHOLD INFORMATION  


    • Total family size: *
      Total number in family under 18:

    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • 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. 

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    • FINAL SIGNATURE AND REQUIRED DOCUMENTS  
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    • 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
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