Student Registration for LifeWise Marysville
Student information
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
Grade for 23-24 school year
*
Please Select
1
2
3
4
School name
*
Please Select
Edgewood Elementary
Raymond Elementary
Classroom / Homeroom Teacher
*If known
Parent #1 information
Name
*
First Name
Last Name
Email Address
*
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent #2 information
With shared parenting/guardianship, both parents' information and signatures are needed.
Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student needs
Please list any student health concerns or food allergies we should be aware of:
Please list any accommodations/interventions your child uses to be successful in the classroom (ie. IEP, 504 plan, modified schedule, sign language):
Parent permission
With shared parenting/guardianship, both parents must sign this form.
I consent to the photography or video of my student while in LifeWise, for promotional purposes.
*
Yes
No
Signature of Parent #1
*
Clear
Signature of Parent #2
Clear
Submit
Should be Empty: