Student Enrollment Form

2024/2025 Enrollment Form

Please answer all questions. Forms with missing information will not be accepted.
Today's Date*

MonthDayYear
Date
Student's Full Legal Name:*

First NameMiddle NameLast NameSuffix
Birthdate*

MonthDayYear
Date
SSN:*
City & State of Birth:*
Birthplace County*
Gender:*
Grade:*
Age:
Address of Student:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity:*
Parent/Guardian Information:*

First NameMiddle NameLast NameSuffix
Parent/Guardian Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone #: *
Please enter a valid phone number.
Home Phone #*
Please enter a valid phone number.
Work Phone #
Please enter a valid phone number.
Email
example@example.com
Does the student reside with this individual?*

YesNo
Does this individual have legal custody?*

YesNo
Does this student have an IEP/ETR?*

YesNo
I certify that the information reported on this enrollment form is accurate.*

Clear
Sign Signature Here
SSID#
Office Use Only
Official Start Date

MonthDayYear
Office Use Only
It is the policy of Rise & Shine Academy to provide equal opportunities in all of its educational programs and operations and in areas of employment practice, and to ensure that there shall be no discrimination against any employee, applicant, or student on the basis of age, race, color, religion, disability, sex, national origin, or ancestry. Rise and Shine Academy is an equal opportunity employer.

RISE & SHINE ACADEMY EMERGENCY MEDICAL FORM 2024/2025

The purpose of this form is to enable parents/guardians to authorize the provision of emergency medical treatment for a child who becomes ill or injured while under school authority when parent or guardian cannot be reached.
Student Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate

MonthDayYear
Date
Grade:*
List in order how contacts are to be made in the event of an emergency, discipline, attendance, etc. Please do not forget to include yourself in the list of emergency contact. (Include work phone.)
Contact 1*

First NameLast Name
Relationship:*
Phone Number*
Please enter a valid phone number.
Contact 2*

First NameLast Name
Relationship:*
Phone Number*
Please enter a valid phone number.
Contact 3*

First NameLast Name
Relationship:*
Phone Number*
Please enter a valid phone number.
I herby give consent for the following medical care providers and local hospital to be called:
Doctor

First NameLast Name
Phone Number*
Please enter a valid phone number.
Hospital:
Phone Number*
Please enter a valid phone number.
In the event reasonable attempts to contact me have been unsuccessful, I herby give my consents for (1) the administrations of any treatment deemed necessary by above named doctor or by another licensed physician or dentist (providing the designated physician or dentist is not available); and (2) the transfer of the child to any hospital reasonable accessible.

Facts concerning the child’s medical history, including allergies, medications being taken, and any physical impairment to which a physician should be altered:

This information may be shared with school personnel if it is pertinent to my child’s health and safety, educational progress, and/or behavioral management plan.
Parent/Guardian Signature:*

Clear
Date*

MonthDayYear
Date
To Not Grant Consent: I DO NOT GIVE CONSENT for emergency medical treatments for my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action:

PICTURE/PUBLICATION RELEASE
My Childstudent name may be photographed for classroom activities, newsletters/newspaper articles, or any other publications pertaining to Rise and Shine Academy.
My Childblanks may NOT be photographed for classroom activities, newsletters/newspaper articles, or any other publications pertaining to Rise and Shine Academy.
Signature:

Clear
INTERNET USAGE
As the Parent/Guardian of blanks I grant permission for my minor child to use Rise and Shine Academy’s Internet Service. Knowing that some materials on the Internet may be objectionable, I accept full responsibility for the guidance of my child’s Internet use.
As the Parent/Guardian of blanks I DO NOT grant permission for my minor child to use Rise and Shine Academy’s Internet Service. Knowing that some materials on the Internet may be objectionable, I accept full responsibility for the guidance of my child’s Internet use.
Signature:

Clear
DRESS CODE, TRUANCY, & LATE PICK UP

Please read Rise & Shine Academy's Dress code, Truancy, and Late Pick-Up Notices
I acknowledge that I have received Rise and Shine Academy's dress code policy, Truancy guidelines, and late pick up notice. I agree to the terms listed and will abide by the policies and procedures described.

Clear

ADDITIONAL ENROLLMENT DOCUMENTS

Listed below are items needed to complete your application packet. Please note that your child cannot be enrolled into Rise and Shine Academy without them. Please call the school at 419-244-9900 Mon- Thursday 9:00a.m.-2:00p.m. to schedule a time to submit your additional enrollment documents and obtain important school information.
The following documents are REQUIRED for your child to be enrolled into Rise & Shine Academy. Your child is not enrolled until these documents are submitted to the school. Once we receive the required documents we will contact you with your enrollment status.

The additional documents needed are as follows:
- BIRTH CERTIFICATE
- UPDATED SHOT RECORDS (Shot records can be faxed to the school at 419-244-9906)
- 2 PROOFS OF RESIDENCY
- FOOD ALLERGY LIST FROM PCP (If applicable)
- IEP/ETR from previous school (If applicable)
Please call the school at 419-244-9900 Mon-Thursday 9:00a.m.-2:00p.m. to schedule a time to submit your additional enrollment documents and obtain important school information.
Should be Empty:

2024/2025 Enrollment Form

RISE & SHINE ACADEMY EMERGENCY MEDICAL FORM 2024/2025

RISE & SHINE ACADEMY 2024/2025 FOOD ALLERGY ASSESSMENT

PICTURE/PUBLICATION RELEASE

INTERNET USAGE

DRESS CODE, TRUANCY, & LATE PICK UP

ADDITIONAL ENROLLMENT DOCUMENTS