I Am Student Registration Form 2022-23

OTHER SCHOOL AGE CHILDREN LIVING AT HOME

	Child’s Name (First & Last)	Relation to Student	School	Gr.	Child’s Name (First & Last)	Relation to Student	School	Gr.
1
2
3

Domicile is defined as the place where parents/guardians have their true and fixed, permanent home and to which they have, whenever absent, the intention of returning. The parent/guardian's domicile determines the student's domicile. Common indicators of domicile are home ownership or in the absence of home ownership a residential lease. 837.06 False official statements.—Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.

This is to certify that all the information on this registration form is true to the best of my knowledge and belief. I understand that inadequate information may result in delayed entry. Falsification of information will forfeit student's athletic and extracurricular eligibility for one (1) calendar year from the date of discovery of the violation.
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Relationship to Student
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Relationship to Student

837.06 False official statements.—Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.

This is to certify that all the information on this registration form is true to the best of my knowledge and belief. I understand that inadequate information may result in delayed entry. Falsification of information will forfeit student's athletic and extracurricular eligibility for one (1) calendar year from the date of discovery of the violation.
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Relationship to Student
Parent / Guardian Signature

Clear
Date

MonthDayYear
Date
Relationship to Student

Medical Information/History
Student Number
Name

First NameLast NameSuffix
Medicine Currently Taking (Prescription and Over-the-Counter (OTC)
Medical History/Physical Limitations
Allergies to Medication, Food, or other substances.

Emergency Consent

In the event of an incident or emergency and I cannot be reached, I consent and request additional contacts listed above be notified of my child’s condition and/or of emergency medical services response to the incident.

SCHOOL HEALTH SERVICES

I hereby give my consent for this child to participate in the School Health Services Program. My child will receive emergency care in school, and health appraisals including vision, hearing, growth and development.

If, upon administering a vision screening through the school or any other school program, my child is determined to have a need for a follow-up vision examination and if my child is eligible or otherwise financially qualified, I hereby authorize for I Am Academy for Lifelong Learning. Inc or a designated third party to provide a no-cost comprehensive vision examination by a licensed optometrist which may include dilation, refraction, and glasses if prescribed.

In the event of an EMERGENCY, I understand that the school will access the 911 emergency medical system immediately. To expedite care, I give my permission for school personnel to provide medical information to the responding emergency team to initiate treatment and transport to an appropriate facility. I give my permission to first responders, medical personnel, and staff to initiate treatment immediately upon arrival. I request to be notified of my child’s condition and admission as soon as possible. If I cannot be reached, I request that the admitting facility notify one of the other persons listed above of my child’s condition and admission. I agree to be financially responsible for my child’s total treatment and transport. For students with an IEP or receiving ESE related services, I authorize I Am Academy for Lifelong Learning, Inc. to release and exchange my child’s confidential information to agencies of the State of Florida which would

allow I Am Academy for Lifelong Learning, Inc.to verify Medicaid eligibility, bill Medicaid for reimbursable Certified

School Match services reference on my child’s IEP and receive Medicaid reimbursement for Exceptional

Student Education (ESE) services it provides to my child while at school. I understand that my child will

continue to receive services referenced on his/her IEP whether or not I give consent.

Please print and sign this page. Upload or take this page along with the student's Social Security card to the school Registrar to finalize authorization.

By signing this form, I accept and acknowledge the terms herein.
Parent/Guardian

Clear
Date

MonthDayYear
Date
*I Am Academy for Lifelong Learning, Inc. is authorized to collect social security numbers (“SSN”) of students as set forth in Sections 1008.386 and 119.071(5)(a)6, Florida Statutes.The provision of a student’s SSN on the enrollment form is optional and is not required as a condition for enrollment within the school. Any SSN provided in connection with enrollment will only be used for research, reporting and recording purposes. The collection of the SSN shall not be used for immigration enforcement. Providing the student’s SSN to I Am Academy for Lifelong Learning, Inc. for these purposes means that you consent to the use of the student’s SSN in the manner described.

Florida Statute §837.06 provides that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree.

(This form is effective from the date of application until the date of withdrawal from I Am Academy for Lifelong Learning, Inc.)

I Am Academy for Lifelong Learning Authorization for Release of Information
Student Number
To Whom It May Concern:

The following student has enrolled at our school. Please send all records including grades, courses taken, test scores, special education, psychological data, current individualized education plan (IEP), health records and immunization dates. Also, please include all grades earned this school year and/or withdrawal grades, if any.
Student’s Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Parent(s)/Guardian(s) Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name of Last School Attended
Complete Mailing Address of Last School Attended

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax #
Send Requested Records To
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date

I Am Academy for Lifelong Learning Inc. Learning Coach Acknowledgement.
We want to ensure that all enrolling families are aware of School Policies and Enrollment Expectations. I Am Academy for Lifelong Learning, Inc. requires that each student has a designated adult, known as the Learning Coach, who will have the primary responsibility of being actively involved in all school related work and activities. Learning Coaches are the primary point of contact for all teachers and Academic Staff. If parents or guardians choose to select someone other than yourself as the Learning Coach, please note that Legal Guardians are still ultimately responsible in ensuring adherence to school policies.

A Learning Coach actively monitors, assists, and motivates the student on a daily basis to ensure academic progress and adherence. The role and responsibilities of the Learning Coach varies based on the student’s grade level.

Grades K- 5th

In grades K-5, the Learning Coach works side-by-side with a student to facilitate progress through daily lessons. While the teacher oversees all facets of the instructional experience for each subject, the Learning Coach’s constant guidance and support through each lesson is critical for a young learner. The Learning Coach communicates regularly with the student’s teacher and establishes proper scheduling, pacing and advanced preparation for lessons. A K-5 Learning Coach ensures that the student is making adequate progress in all courses and meeting program expectations. Learning Coaches of K-5 students can expect to spend 3–6 hours per day supporting their child's education.

Grades 6th- 8th

In Middle School students begin to develop more independence and take a more active role in their learning. The support of a Learning Coach is critical during this transition. A Middle School Learning Coach is responsible for working closely with the student’s teacher(s) to monitor all aspects of a child’s online schooling experience. The Learning Coach ensures that the student is engaged in schooling each day, meeting program requirements and deadlines, staying on track with scheduling and pacing, and collaborating with his teacher when additional support is needed. While students begin to gain independence in Middle School, they still need consistent guidance and support from a Learning Coach to ensure academic success. Learning Coaches of Middle School students can expect to spend 2–4 hours per day supporting their child's education.

Grades 9th- 12th

In High School the Learning Coach is referred to as the student’s Mentor. The Mentor helps the student stay on task and ensure the student is following through on his or her assignments while the student is expected to manage his or her own time and schedule directly. High School courses are taught by teachers specifically experienced in their respective subjects, so the student has a different teacher for each subject. These teachers are responsible for reviewing all student work and providing instructional feedback. The student is expected to move at a consistent pace with her or his class in each subject.

Please review the Enrollment Verification document before selecting the student’s Learning Coach to ensure you fully understand this role and its responsibilities.
Learning Coach Information
Who will be the student’s learning coach?

I, the parent or legal guardian who is enrolling the student will be the Learning CoachAnother responsible adult will be the Learning Coach
If another responsible adult will be acting as Learning Coach, please provide their information below
Name

First NameMiddle NameLast Name
Primary Phone
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Email
example@example.com
The provided email address will be the primary communication used for sending and receiving information about your child’s education, including grades, assignments, and other information about his or her progress. Please ensure only adults who have authorized access to the student’s educational record have access to this email inbox. As a reminder, Learning Coaches should check their email account daily.
Learning Coach Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

I Am Academy for Lifelong Learning Inc. Agreement for Use of Instructional Property
The Responsible Party is the parent or legal guardian of the Student, who is enrolling the student. It is the expectation of I Am Academy for Lifelong Learning that all parents or legal guardians insure and provide the student they are enrolling, with digital devices and internet access.

I Am Academy for Lifelong Learning has made arrangements with VIP and/or its affiliates to permit each Student to use certain equipment, software, and related instructional books and materials (“Instructional Property”) to facilitate the Student’s education while enrolled in the school.

Responsible Party hereby agrees to the following:

1. Use of Instructional Property. I Am Academy for Lifelong Learning and its VIP shall permit the Student and the Responsible Party to use certain Instructional Property as required and listed in each course syllabi. The school and its VIP reserve the right to add, change, substitute, and/or delete individual items on the Instructional Property Schedule from time to time.

2. Term. Responsible Adults and Student’s rights to use and possess the Instructional Property expire upon the Student’s termination of enrollment. Notwithstanding the foregoing, the school and its VIP reserve the right to terminate any right to use and possession immediately if either has reason to believe that any term or condition of this Agreement is being violated. Responsible Party shall return all the Instructional Property as instructed within five (5) days of the termination date in the same condition as delivered, normal wear and tear excepted.

3 Ownership. At no time shall legal title to or ownership of any of the Instructional Property vest in the Responsible Party or Student, who shall only have the rights to temporary use and possession as provided herein.

4. Condition of Instructional Property. The Responsible Party agrees to fill out, sign, and return the Instructional Property Receipt Acknowledgment Form (to be enclosed with Instructional Property) to the school to acknowledge receipt of the Instructional Property and to affirm that it is all in satisfactory operating condition upon receipt.

5. Responsibility for Instructional Property. Responsible Party must maintain the Instructional Property at the Responsible Party’s residence set forth as the shipping address in the enrollment form unless Responsible Party provides thirty (30) days’ written notice and the new address to the school. The Responsible Party shall be solely liable for any loss or damage to the Instructional Property until it is received back by K12 and shall take all reasonable precautions to protect it. The Responsible Party agrees to inform the school of any loss or damage to the Instructional Property from any cause whatsoever within three (3) days of the loss or occurrence of damage. The school and/or K12 will provide the Responsible Party with a loss report form that will include provisions for the Responsible Party to pay for the lost or damaged Instructional Property and, upon receipt, will allow the school to ship or have shipped replacement Instructional Property.

6. Maintenance and Repair (only applicable if you receive any equipment). Responsible Party is responsible for maintenance and repair of the Instructional Property while in his or her possession and will follow all instructions for Instructional Property requiring repairs as directed byVIP Technical Support and the Warranty Agreement with the Original Equipment Manufacturer. Responsible Party is solely responsible for upgrading to new software versions when publicly available, obtaining and installing antivirus file updates, and overall maintenance of each software application provided.

7. Use of Instructional Property (Section (v) is only applicable for those receiving equipment). Responsible Party agrees that: (i) Instructional Property may be used solely for the education of the Student while enrolled at the school and not for the benefit of any other person or for any other purpose,(ii) all Instructional Property shall be used in accordance with the school policies and rules and K12’s and the manufacturer’s instructions, (iii) each software application provided shall be subject to, and used in accordance with, the license and/or use agreement that accompanies that software application, (iv) all usage of the Instructional Property shall be subject to the school policies and rules regarding Network/Internet use and protocol, (v) Responsible Party is solely responsible for ensuring that the software settings, default configurations, and administrative privileges are maintained at the original specified settings that the Instructional Property had upon delivery and will be liable for any resulting damage to the Instructional Property, any files, and/or other software applications if these default settings are changed or modified without explicit authorization from VIP Technical Support, and (vi) The Responsible Party is solely responsible for keeping User IDs and passwords confidential to prevent unauthorized usage and understands that passwords should be changed on a monthly basis.

8. General Indemnity. The Responsible Party agrees to indemnify, defend, and hold harmless the school,VIP, and any sponsoring School District or Authority, their respective employees, officers, directors, agents, assignees, and all affiliated companies

and/or entities (“Indemnified Parties”) from and against any and all claims, actions, suits, proceedings, costs, expenses (including, without limitation, court costs and attorney fees), damages, obligations, judgments, orders, penalties, fines, injuries, liabilities, and losses arising directly or indirectly out of or in connection with any matter covered by this Agreement, other than those caused by the school or VIP.

9. DISCLAIMER OF WARRANTIES. NO INDEMNIFIED PARTY MAKES ANY WARRANTY OR REPRESENTATION, EITHER EXPRESS OR IMPLIED, AS TO THE VALUE, DESIGN, CONDITION, MERCHANTABILITY, OR FITNESS FOR A PARTICULAR PURPOSE, OR FITNESS FOR USE OF ANY OF THE INSTRUCTIONAL PROPERTY. IN NO EVENT SHALL ANY INDEMNIFIED PARTY BE LIABLE FOR ANY ACTUAL, INCIDENTAL, DIRECT, INDIRECT, SPECIAL, OR CONSEQUENTIAL DAMAGES IN CONNECTION WITH OR ARISING OUT OF THIS AGREEMENT, OR THE EXISTENCE, FURNISHING, FUNCTIONING, USAGE, OR MAINTENANCE OF ANY INSTRUCTIONAL PROPERTY PROVIDED UNDER THIS AGREEMENT.

10. Insurance. The Responsible Party agrees to maintain at his or her expense adequate insurance to cover damage to the Instructional Property by fire, theft, flood, explosion, accident, act of God, or other cause to the full replacement value of the Instructional Property and agrees that he or she will be financially liable for it regardless of the availability of insurance proceeds.

11. Miscellaneous. The Responsible Party represents that he or she has the power to bind all of a Student's parents or legal guardians, all of whom shall be bound by these terms. The Responsible Party cannot amend this Agreement unless accepted in writing by an authorized representative of the school. This Agreement shall constitute the entire agreement between the parties with regard to the Instructional Property and any prior understanding or representation of any kind shall not be binding on either party, except to the extent incorporated herein. The waiver of any right under this Agreement by either party shall not be construed as a waiver of the same right at a future time or a waiver of any other right under this Agreement. This Agreement shall be construed and enforced in accordance with the laws of the state of the school.

Appendix 1: Instructional Property Schedule (only applicable if you receive any equipment)

Hardware THE SCHOOL may provide or cause to be provided the following computer and peripheral equipment:

□ Desktop computer or Laptop

□ Monitor

□ Printer

Software THE SCHOOL shall provide or cause to be provided the following software applications (the “Software”):

□ Office Software Suite

□ Antivirus software

□ Filtering software

□ The school may also provide other software.

By Signing below, you agree to the Agreement for Use of Instructional Property
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Signature Date

MonthDayYear
Date

Required Documents

Please Upload the following documents
Verification of Guardianship

• State Issued Photo ID of Registering Adult

• Birth Certificate of Student and/or If applicable: must provide Court Documentation (such as divorce decrees w/parenting plan or the placement of children though court)
Verification of Guardianship

Cancelof
Verification of Student Legal Name
• Birth Certificate
Verification of Student Legal Name

Cancelof
Verification of Student Age* (with one of the following):

• Birth Certificate

• Passport
Verification of Student Age

Cancelof
File Upload

Cancelof
Verification of Immunization

• Proof of immunizations on a Form 680
Verification of Immunization

Cancelof
Physical Exam

• Proof of physical examination by a U.S. doctor within a year of enrollment (first day of entry at school).
Physical Exam

Cancelof
Verification of Academic History

• Transcript

• Withdrawal Form

• Last 2- semester report card
Verification of Academic History

Cancelof
Verification of Special education information (if applicable)

• Current IEP

• Current 504 plan
Verification of Special education information (if applicable)

Cancelof
Verification of your residence (with one of the following):

• Current Homestead Exemption Card,

current property tax statement or signed Settlement Statement

• Current signed lease (Additional documentation could be requested)

• Verification of address:
Verification of your residence

Cancelof

Student Registration Fee
Student Registration Fee*

prevnext( X )
USDDescription

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

STUDENT INFORMATION

ADDITIONAL STUDENT INFORMATION: If the answer is "yes" to any of these questions, the student will be tested for English Proficiency.

LAST THREE SCHOOLS ATTENDED (Begin with the most recent – For Kindergarten registration – please, list Pre-K)

1ST TIME KINDERGARTEN STUDENTS

Student Contact Information

1st PARENT/GUARDIAN INFORMATION (Please list parent/guardian in order of contact priority.)

2nd PARENT/GUARDIAN INFORMATION (Please list parent/guardian in order of contact priority.)

Other Contact - Relationship

Medical Information/History

2021-2022 Student Residency Questionnaire

I Am Academy for Lifelong Learning Authorization for Release of Information

I Am Academy for Lifelong Learning Inc. Learning Coach Acknowledgement.

Learning Coach Information

If another responsible adult will be acting as Learning Coach, please provide their information below

Learning Coach Address

I Am Academy for Lifelong Learning Inc. Agreement for Use of Instructional Property

Required Documents