Student Enrollment Form 1 Welcome2 Student Information3 Parent / Guardian Information4 Request for Permanent Record5 Student Health Information6 Student Emergency Care Info7 Emergency Care Plan8 Media Release Form9 Scholar Seat Acceptance Form Welcome Families, Thank you for your interest in Leadership Preparatory Charter School. We are accepting applications for Kindergarten through 6th Grade for the 2020-2021 school year. We look forward to ensuring your child is on the path to college! In order to complete the enrollment process, you will need to fill out the attached application and return it to a Leadership Preparatory Charter School representative. If you have any questions/concerns, please feel free to stop by the school (4190 Elliston Road, Memphis, TN 38111) between 8am-4pm Monday through Friday, call our Main Office at (901) 512-4495, or email outreach@leadmemphis.org. In addition, we must have copies of the items listed on the next page in order to complete your enrollment. If you need us to make copies of the required documents, we can do that for you at the school. Failure to provide all necessary documents in a timely manner may result in your student being placed on the admissions waitlist. There are no academic, financial, or other requirements for admission. Please note the following, as it pertains to enrollment eligibility: Children must be 5 years of age on or before August 15, 2020 in order to enroll in Kindergarten Children must have completed Kindergarten before enrolling in the 1st Grade New Scholar Enrollment Packet Checklist Parent Documentation Photo ID of parent/guardian Proof of Home Address (i.e. copy of rent or utility bill) Student Documentation Birth Certificate/Passport Social Security Card Certificate of Immunization (Note: Must be on Tennessee Department of Health Form) Previous year report card (Required for grades 1 and up) Leadership Prep Forms (See Attached) New Student Registration Form Parent/Guardian Contact Information Request for Permanent Records Student Health Information Student Emergency Care Information Emergency Care Plan Photo/Video/Media Release Form Seat Acceptance Primary Home Language identification Form Occupational Survey Student InformationName* First Middle Last Address* Address Apt. No City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number*Date of Birth*Gender*MaleFemaleAre You Hispanic/LatinoYesNoRacial IdentityWhiteBlackAsianNative/Pacific IslanderIndian/Alaska NativeParent/Guardian InformationParent/Guardian Name* First Last Phone #1*Phone #2Email* Academic & Home Life ExperiencePrevious school attendedPlease request transfer records to be sent to Leadership Preparatory Charter SchoolReason for transferDoes the student receive any special education services (IEP, speech, audio behavior)?YesNoAt home, does your scholar have access to the following items?*ComputerInternetDoes the scholar have any siblings attending LPCS?*YesNoList sibling names* Parent/Guardian Contact InformationScholar Name First Last GradeSchool Year:2020-2021Primary ContactParent / Guardian Name First Last Relationship*Primary Phone Number*Secondary Phone NumberEmail Address* Does scholar live with primary contact?*YesNoAddress (if different from scholars)Secondary ContactParent / Guardian Name First Last RelationshipPrimary Phone NumberSecondary Phone NumberEmail Address Does scholar live with primary contact?*YesNoAddress (if different from scholars) Request for Permanent Records | 2020-2021 School YearName of Scholar* First Last has enrolled in Leadership Preparatory Charter School and the student’s first day will be August 5, 2019. Please send the following information to: Leadership Preparatory Charter School 4190 Elliston Road Memphis, TN 38111 Phone: (901) 512-4495 Fax: 901-512-6852 Email: outreach@leadmemphis.org Information Cumulative Records Physician’s Record Dental Record Special Education (IEP/ETR) Copy of Students Data Form Expulsion/Suspension Documents Grade Card Immunization Record Birth Certificate Name of School Child Last Attended*School District*School Address* Street Address City Zip Code Last Grade Attended*PreKK123456In accordance with the Family Educational Rights and Privacy Act dated June 17, 1976, parental permission is no longer required when records are requested by authorized school personnel.Signature of Parent/Guardian*Date*Thank You, Leadership Preparatory Charter School Student Health InformationYour child’s learning depends upon good health. Please complete this form with information you are comfortable sharing. Health conditions currently affecting your child are of greatest significanceStudent Name* First Last Gender*MaleFemaleDate of Birth*Grade*K123456Allergies?*YesNoPlease list allergiesHas the allergy required emergency care in the past?*YesNoYes, please explainDoes the child use emergency medication for an allergy?*YesNoYes, please explainPlease indicate if there are health concerns that pertain to the student* None Asthma Skeletal Problem Frequent Infections Anxiety Bladder Breathing Condition Sleeping Disorder Diabetes Glasses/Contacts Ear Infection Bi-polar Required Diapering Dental Issue Skin Rashes/Lesions Epilepsy/Seizures Lazy Eye Hearing Aid OCD Bowel Condition Neurological Problem Eating Disorder Heart Condition Crossed Eyes ADD/ADHD ODD Special Diet Nosebleeds Surgery (check all that apply)Please explain in more detail any items that you have circled above.Does your child require special health care or need to be restricted during specific activities?*Other health information or concerns:Your child’s health and education are extremely important to us. The above information will be used to facilitate your child’s learning. Informing and educating staff about the needs of your child will help promote his/her well-being. Confidentiality will be maintained and the information will be shared with those responsible for the sole purpose of meeting the care and custody of the child’s medical needs. Consent*Yes, I give permission to share health information with Leadership Prep staff as needed.No, I do NOT give permission to share health information with Leadership Prep staff as needed.Signature of Parent/ Guardian:Date* Student Emergency Care InformationDear Parent/Guardian, Thank you for completing your child’s Student Health Information form. If your child has a medical condition that requires attention/assistance, we ask that you: Complete and sign the attached Emergency Care Plan and the “Parent/Guardian” section of the Medication Administration Form. Have your child’s health care provider complete and sign the “Health Care Provider” section of the attached Medication Administration Form. Return the signed forms to the Leadership Preparatory Charter School Office. Please note: No medication will be administered or self-administered at school without a Medication Form completed and signed by your child’s health care provider and you. One Medication Administration form is needed for each medication. The medication must be delivered to the school in a pharmacy-labeled container with clear instructions. Medical information will be shared with school staff on a need-to-know basis to ensure the health and safety of your child. If you feel that your child’s medical condition does NOT need assistance at school, please sign below and return this letter to the school. My child does NOT need Services.Student Name* First Last Date of Birth*Parent / Guardian Name* First Last Parent/Guardian Signature*Date* Emergency Care PlanThe purpose of this document is to enable parents and guardians to authorize the provision of the emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.Student Name* First Last Gender*MaleFemaleDate of Birth*Adults Who Have Permission to Pick Up Your ChildName*Relationship to Student*Phone Number*NameRelationship to StudentPhone NumberAdults Who DO NOT Have Permission to Pick Up Your ChildNameRelationship to StudentPhone NumberNameRelationship to StudentPhone NumberAdult/Entities Who May Grant Consent for My Child to Receive Medical TreatmentName*Relationship to Student*Phone Number*Family Doctor Name*Location*Phone Number*In the event reasonable attempts to contact me (parent/guardian) have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or, in the event the designated preferred practitioner is not available, by any licensed physician or dentist, and (2) the transfer of the child to any hospital reasonable accessible. This authorization does not cover major surgerySignature of Parent/GuardianDateI do NOT give permission for emergency medical treatment to my child. In the event of illness or injury requiring emergency treatment, I would like for the school authorities to take the following actions:Signature of Parent/GuardianDate Photo/Video/ Media Release FormDear Parent/ Guardian, On occasion, representatives from the media wish photograph, videotape, and/or interview students in connection with school programs or events. Educating the public is one of our objectives, and the entire community benefits from knowing about the needs and abilities of our students and about the programs we offer to children and families. In order to release student photos, video footage, comments, and/or post on our social media page or website, we need written permission. To give your consent, please complete the form below.I,Parent / Guardian Name* First Last , parent/guardian ofStudent Name* First Last give permission for my child to be photographed, videotaped, and/or interviewed by representatives from the media for the purpose of publicizing educational programs. I authorize Leadership Preparatory Charter School or anyone authorized by the Leadership Preparatory Board of Directors the use and reproduction of any and all photographs/videotapes taken of my child, without compensation to me/my child. All of the photographs/video recordings shall be the property, solely and completely, of Leadership Preparatory Charter School. I waive any right to inspect or approve the finished photographs/videotapes, sound track, script, or printed manner that may be used in conjunction with them.Signature of Parent/Guardian*Date Leadership Prep Scholar Seat Acceptance FormAs a Leadership Prep Scholar, I pledge to: Attend school every day, on time, without exceptions or excuses Arrive “prepped-up”, prepared, and ready to learn Attend all required after-school tutoring, Saturday Opportunity Days, and/or Summer Academy Complete all my homework, read 30 minutes every night, and prepare for all tests Always strive to show iLEAD values (Integrity, Leadership, Enthusiasm, and Determination Use my gift, talents and dedication to work hard and prepare myself for college and beyond As a Leadership Family, we pledge to: Attend all family conference and major school events Ensure students are in full uniform every day Ensure reliable transportation for your child for school, and other required events Review and sign any academic or behavioral reports Engage in advocacy efforts to create great public schools for every student in Tennessee By signing this form, you are agreeing to enroll at Leadership Prep, abide by the pledges above to the best of your ability, and agree to all items found in our Student Handbook, which will be provided to you at the start of the new school year. Scholar Name* First Last Scholar Signature*Parent/Guardian Signature*DateCAPTCHA
