Enrollment Form

Leading Edge Academy Enrollment Form ( page 1 of 5)
STUDENT INFORMATION
Please select the campus you are applying for:
How did you hear about Leading Edge Academy? (select all the apply) Friend Recommendation Past Student Drive By Site Signs Newspaper TV Theater Community Event Church Other
Student's LEGAL Last Name	Student's LEGAL First Name	Student's LEGAL Middle Name		Jr., Sr., III, etc.	Gender M F
(If different from above) Last Name Student Goes By	(If different from above) First Name Student Goes By	Age	SAIS Number (If known)	Grade Student Entering
Date of Birth	City of Birth	State	Country of Birth
Student Home Phone #	Student Cell Phone #	Student Email Address
PREVIOUS SCHOOL INFORMATION (New Enrollments Only)
Returning Student New Student	Name of Previous/Current School Attended		Previous/Current School Address (City, State, Zip)
Sibling Enrolled at Leading Edge? N Y If yes, Name:	Previous/Current School Phone	Withdrawal Date From Previous School		First Date at Leading Edge

Leading Edge Academy Enrollment Form (page 2 of 5)
FAMILY/GUARDIAN INFORMATION
1)
Name	Address	City		State	Zip
Home Phone	Work Phone	Cell Phone		Email Address
Mother Father Other:		Student Lives With? Yes No		Call in Emergency? Yes No
2)
Name	Address	City		State	Zip
Home Phone	Work Phone	Cell Phone		Email Address
Mother Father Other:		Student Lives With? Yes No		Call in Emergency? Yes No

Leading Edge Academy Enrollment Form ( page 3 of 5)
STUDENT BACKGROUND
If separated/divorced, who has legal custody? Mother Father Joint Custody	Does the non-custodial parent have restricted visitation rights? No Yes (If yes, a copy of the legal papers must be provided.)
Are there confidential, psychological, or special education reports from student's former school? No Yes If yes, contact person Contact phone
Designate any special services your child has received: Special Education/Handicapped Remedial Reading Remedial Math Speech/Language Title I Gifted Other:
Has your child ever been, or is in the process of being, suspended or expelled from another school? No Yes Please specify:
Has your child ever been held back in any grade? No Yes If yes, which grade: Reason?
We are required to provide yearly ethnic information to the Office of Civil Rights and State Attendance Records. Please Check At Least One: White (Not Hispanic Origin) Black (Not Hispanic Origin) Hispanic Asian/Pacific Islander Native American/Alaskan Indian - Tribe(s)

Leading Edge Academy Enrollment Form ( page 4 of 5)
EMERGENCY CONTACT INFORMATION
Please list at least two people not listed as Parent/Guardian who could assume temporary responsibility in case of illness or injury. Contacts wlil be called in the order listed beginning with parent/guardians listed on page one of the Enrollment Form. Students will only be released to persons below unless otherwise authorized by parent or guardian.
1)
Name: Relationship: Home Phone: Cell Phone: Work Phone:
2)
Name: Relationship: Home Phone: Cell Phone: Work Phone:
The following persons may NOT remove my child from school: Name: Name:
STUDENT HEALTH INFORMATION
Physician's Name (optional): Phone: Hospital Preference (optional):
Has your child been certified as having a chronic health problem? No Yes Please specify: Is your child on daily medications? No Yes Please specify: Recent surgery, accident, or illness within last 12 months? No Yes Please specify:
Health Concerns? Heart Diabetes Asthma Hearing Vision Other Additional Comments and Special Instructions:
I PERMIT DO NOT PERMIT acetaminophen to be given to my child at the health assistant's discretion.

Leading Edge Academy Enrollment Form ( page 5 of 5)
ACKNOWLEDGEMENT AND CONSENTS
The Student Handbook and the Student Code of Conduct have been made available to me and my Student (these documents are available online at www.leadingedgeacademy.com on the "about us" page). I understand that the handbook contains information that my student and I need during the school year and that all students will be held accountable for their behavior and will be subject to the disciplinary consequences outlined in the Code of Conduct. I understand that the Family Educational Rights and Privacy Act (FERPA) and state law allow for directory information on my student to be released by the school to those who request it, unless I object in writing to the release of this directory information. I also understand that to be in compliance with the No Child Left Behind Act of 2001, the school may release directory information (name, address, and telephone number) of my student to military recruiters and institutions of higher learning. I may direct this information not be released without my written notification. I understand that this objection must be filed with the principal within ten days of the first day of instruction. Complete FERPA statement is in Handbook. I understand that resume and related information for all teachers who provide instruction is available at each campus office. I understand that other information or update, if required to be disclosed, will be posted on the school website. The school may release a student directory. Various other forms of media may be pulished by Leading Edge Academy during the school year. These publications may include (but are not limited to) a yearbook, newsletters, brochures, websites, Parent Access System, video, programs, and class projects. Please indicate below your authorization for your child's information and photograph to be used in these publications.
I acknowledge that Handbook & Conduct Code have been made available to me	Yes No
I acknowledge that FERPA Information has been made available to me	Yes No
I acknowledge that I've been informed that Teacher Resumes are available at Campus office	Yes No
I consent to students image, name and other related directory information to be published in the student directory, student yearbook, and other school materials.	Yes No
I consent to students attendance, grades, health, and classroom/school information being available on the internet based Parent Access Support System (PASS). PASS is accessible through a secure server by parents or guardians using a unique student ID and secret PIN number.	Yes No
I consent for my student to attend occasional, local off-site educational opportunities and field trips, such as the library, parks, community college (for upper grades), and other local venues. Transportation will usually be provided by school vehicle and/or parent volunteers. When applicable, notice will be sent home in advance via the student or email. Individual Activity Field Trip permission forms will normally be used for Field Trips requiring money and/or those further and longer in nature.	Yes No
Enrollment Consent Evaluation of student's previous records is required before enrollment. By signing below consent is given to Leading Edge Academy to receive school records from previous and current schools. We reserve the right to assess student and place in appropriate grade/class. Any falsified information may result in action, including withdrawal of your child. Medical Consent I give my consent for the above named child to be released to the persons I have designated and/or be taken by Emergency Personnel to the nearest medical facility in case of emergency. I understand that Leading Edge Academy does not provide accident medical/dental coverage for students due to injuries/illnesses occurring at school. In case of injury or sudden illness, I, the undersigned parent/guardian, give authority to any hospital or medical personnel to render immediate aid as might be required at the time for his/her health and safety. It is understood by me that any incurred expenses of this service are my responsibility. I have reviewed all five pages, and by my signature acknowledge that the information provided is factual and accurate to the best of my knowledge.
Student Signature (if over age 18) : Date: Parent Signature: Date: Typing your full legal name � first, middle, last - above will constitute your legal signature. Leading Edge Academy is a tuition free public Charter School. In accordance with Federal law Leading Edge Academy does not discriminate on the basis of race, religion, color, national origin, sex, or disability.