• LifeWise Academy Application 2022-2023

    • SCHOLAR INFORMATION 
    •  -
    •  -
    •  - -
      Pick a Date
    • SCHOLAR SCHOOL INFORMATION 
    • Upload a File
      Cancelof
    • Browse Files
      Cancelof
    • SCHOLAR HEALTH INFORMATION 
    • Browse Files
      Cancelof
    • PARENT/GUARDIAN INFORMATION 
    •  - -
      Pick a Date
    •  -
    •  -
    •  -
    • SECOND PARENT/GUARDIAN INFORMATION 
    •  - -
      Pick a Date
    •  -
    •  -
    •  -
    • EMERGENCY CONTACT 
    • In the event of an emergency, LifeWise StL will first attempt to contact the primary parent/guardian and then the second parent/guardian (if one is listed). In the event that both parents or guardians cannot be reached, I authorize LifeWise StL to contact our emergency contact. 

      Please list the name of the emergency contact below. If you have already listed two parents or guardians, then this section is optional. 

    •  -
    •  -
    • HOUSEHOLD INFORMATION 


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

    • EMERGENCY CLAUSE 
    • I understand that I will be notified at once in case of an emergency with my child, and I will make arrangements for the medical care of my child with the physician or hospital of my choice. In the event I cannot be reached in an emergency, I hereby give my permission 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, surgery, and other medical procedures deemed necessary.

    • Clear
    •  - -
      Pick a Date
    •  -
    •  -
    • RELEASES AND CONSENTS 
    • FOR THE FOLLOWING SECTION:

      If you give your consent for each item, please sign and date in the box below that item. If you do not consent, then please leave the signature for that item blank.

       

    • 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.

    • Clear
    •  - -
      Pick a Date
    • CONSENT TO RELEASE SCHOOL INFORMATION

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

      There is a separate Release of Information form that will need to be completed. I will complete the Release of Information form granting authorization.                                                    

                                                                          

    • Clear
    •  - -
      Pick a Date
    • MEDIA RELEASE

      I give permission to allow LifeWise StL and its partners the unlimited right to use photos, videos, direct quotes and/or audio clips that they have of my child participating in LifeWise StL programs or events. This includes 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. 

       

    • Clear
    •  - -
      Pick a Date
    • 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.

    • Clear
    •  - -
      Pick a Date
    • 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 any gains in literacy occurred.

    • Clear
    •  - -
      Pick a Date
    • 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.

    • Clear
    •  - -
      Pick a Date
    • 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.

    • Clear
    •  - -
      Pick a Date
    • 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.

    • Clear
    •  - -
      Pick a Date
    • LEAVING LIFEWISE ACADEMY PREMISES CONSENT

      I hereby give permission 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.

    • Clear
    •  - -
      Pick a Date
    • 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.

    • Clear
    •  - -
      Pick a Date
    • FINAL SIGNATURE 
    • I understand that student, health, parent/guardian, emergency contact and household information will be updated annually, and that my signature grants the above signed permissions for the duration of my child’s participation in LifeWise Academy and that I may withdraw my consent at any time by submitting a request in writing.

    • Clear
    •  - -
      Pick a Date
    • REQUIRED DOCUMENTS FOR SCHOLAR STIPEND ELIGIBILITY  
    • 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
    • Upload a File
      Cancelof
    • Upload a File
      Cancelof
    • Upload a File
      Cancelof
    • Upload a File
      Cancelof
    • Upload a File
      Cancelof
    • Should be Empty: