Updated Academy Application 2022-2023

LifeWise Academy Application 2022-2023

SCHOLAR INFORMATION
Scholar Name*

First NameMiddle InitialLast Name
Scholar's Preferred Name/Nickname:
Scholar Address*

Street Address

Apartment or Unit Number

CityState

Postal / Zip Code
Scholar Phone Number (Cell)*

Area CodePhone Number
Scholar Phone Number (Home)

Area CodePhone Number
Scholar Email*
Scholar Gender*
Scholar Age*
Scholar Date of Birth*

MonthDayYear
Scholar Race/Ethnicity:*
Language spoken at home:*
Who does the scholar live with?*
Scholar Social Security Number:

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

YESNO
IEP/504 Plan/Learning Disability/Special Education/Resource Room/Behavior Plan*

YESNO
If yes, please explain any accommodations/modifications/services that the scholar receives.
*IF YOU HAVE A COPY OF THE SCHOLAR'S IEP/504 PLAN, PLEASE UPLOAD IT USING THE BUTTON BELOW.

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Has there ever been any disciplinary action taken at school?*

YESNO
If yes, please explain:

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

YESNO
If yes, please list conditions or allergies:
Do you take any medications?*

YESNO
If yes, please list medications:
Please let us know if there are any accommodations that the staff at Academy should know about to help support your scholar. For example: does the scholar have an asthma inhaler or an EpiPen that they carry with them?
Do you have any dietary or food restrictions?*

YESNO
If yes, please list restrictions:
*PLEASE PROVIDE A COPY OF YOUR CHILD'S IMMUNIZATION/SHOT RECORDS. YOU MAY UPLOAD A COPY USING THE BUTTON BELOW.

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SECOND PARENT/GUARDIAN INFORMATION
Second Parent/Guardian Name

First NameLast Name
Second Parent/Guardian Date of Birth

MonthDayYear
Second Parent/Guardian Relationship to Child:
Second Parent/Guardian Address (If different from scholar address)

Street Address

Apartment or Unit Number

CityState

Postal / Zip Code
Second Parent/Guardian Cell Phone Number

Area CodePhone Number
Second Parent/Guardian Home Phone Number

Area CodePhone Number
Second Parent/Guardian Work Phone Number

Area CodePhone Number
Second Parent/Guardian Email
Is the second parent/guardian currently enrolled in LifeWise StL services?*

YESNO

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.
Name of Emergency Contact*

First NameLast Name
Emergency Contact Relationship to Scholar*
Phone Number for Emergency Contact*

Area CodePhone Number
Second Phone Number for Emergency Contact

Area CodePhone Number
Emergency Contact Email
example@example.com

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.
Signature of Parent/Guardian*

Clear
Date of signature*

MonthDayYear
Name of Scholar's Primary Physician or Clinic*

First NameLast Name
Primary Physician/Clinic Phone Number

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

Area CodePhone Number

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.
Signature of Parent/Guardian

Clear
Date of Signature

MonthDayYear
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.
Signature of Parent/Guardian

Clear
I do not give consent.

Type option 1Type option 4
Date of signature

MonthDayYear
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.
Signature of Parent/Guardian

Clear
Date of signature

MonthDayYear
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

MonthDayYear
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.
Signature of Parent/Guardian

Clear
Date of signature

MonthDayYear
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

MonthDayYear
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

MonthDayYear
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

MonthDayYear
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.
Signature of Parent/Guardian

Clear
Date of signature

MonthDayYear
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

MonthDayYear

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.
Signature of Parent/Guardian

Clear
Date of signature

MonthDayYear

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
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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I-9

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LifeWise Academy Application 2022-2023