Liberty Academy Elementary Student Application
Kindergarten - 5th Grade
Student Information
Please Fill out one application per child
School Year Applying to
*
Please Select
2023-2024
2024-2025
2025-2026
2026-2027
2027-2028
2028-2029
2029-2030
Registering Parent/Guardian Full Name
*
First Name
Last Name
Student Full Name
*
First Name
Middle Name
Last Name
Student Gender
*
Male
Female
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student's SSN
*
Required for enrollment for the National School Lunch Program
Student Academic Info
*
Rows
Grade Applying For
Returning Student
Step up Scholarship?
StepUp Award ID
School Currently Attending
Reason for Withdrawal
Select from Dropdown
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Yes
No
Yes
No
Need to Apply
Student Medical Info
*
Rows
Student Allergies,Medical or Dietary Needs.
Does Student Wear Glasses?
Does Student use hearing Aid(s)?
Other Info Possibly needed?
Please Answer All Questions
Yes
No
Needs Glasses
Yes
No
Needs Hearing Aide
Student's Previous Education
*
Rows
Yes
No
Has student previously been enrolled in Special Education?
Has student previously been enrolled in Speech?
Has student had an IEP?
Has student had a 504 Plan developed?
Has student been expelled from previous program?
Has student previously been retained?
Has student been referred for any Therapy Services?
Has student been enrolled in a gifted program?
Family Information
Please fill out all required information
Students Lives with
*
One Parent
Both Parents
Legal Guardian
Other
Ethnicity
*
Non-Hispanic or Non-Latino
Hispanic or Latino
Race (Check all that apply)
*
White
Asian
Native American/ Native Alaskan
Native Hawaiian/ Pacific Islander
Black/ African- American
Registering Parent/ or Legal Guardian Information
*
Rows
Infromation
Parent Full Name
Relationship to student
Birth Date
Primary Phone Number
Secondary Phone Number
Email
Home Address
Non-Registering Parent/ or Legal Guardian Information
Rows
Information
Parent Full Name
Relationship to student
Primary Phone Number
Secondary Phone Number
Email
Home Address
Date of Birth
Required Authorized Contacts for Pickup (Please don't not add the parent or guardians)
*
Rows
Name
Relationship to child
Phone Number
Address
Contact #1
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #2
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Additional Authorized Contacts for Pickup
Rows
Name
Relationship to child
Phone Number
Address
Contact #3
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #4
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #5
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
Contact #6
Mother
Father
Aunt
Uncle
Family Friend
Cousin
Grandma
Granddad
I consent to receiving text messages and E-mail from Liberty Academy for application and enrollment purposes.
*
Yes
By checking this box, I give Liberty Academy permission to submit an application for my child for the school year chosen above, using the information I have provided.
*
Yes
Agreement
Submitting this application does not mean or guarantee that the student will be accepted. By completing this application correctly and notifying us of changes, we guarantee that you will be contacted. If the student is accepted because you submitted false, incorrect or misleading information, we may refuse to enroll the student. By signing your name below and submitting this application you are agreeing that the information you provided is true and correct.
Signature
*
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Media Release
Please fill out all information
Media Release Form for all Liberty Academy Students (All Grades)
*
I WILL permit my child to be photographed, videotaped, and/ or interviewed by the media when the news media has secured proper authorization from Liberty Academy and Miami-Dade COunty Schools
I WILL NOT permit my student to be photographed, videotaped, and/or interviewed by the media.
Signature for Media Release
*
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Getting to Know Me K-5
We want to get to know your child better so that we can provide the best possible educational experience. No one knows your child better than you. Tell us more about your child?
1. What are your child's favorite and least favorite toy or activity?
*
2. What calms your child? What upsets your child?
*
3. What are your child's strengths and challenges?
*
4. How does your child communicate?
*
Verbally
With Vocalizations
Through Gestures (i.e. pointing, pulling, blinking)
American Sign Language (ASL)
With Communication devices (i.e. pictures)
Other
5. What services does your child receive?
*
Speech/ Language Therapy
Behavioral
Physical Therapy
Mental Health Counseling
Occupational Therapy
None
Other
6. Does your child require assistive devices or equipment? (i.e., braces, walker, wheelchair, communication device, insulin, nebulizer)
*
Yes
No
If Yes to question 6 please describe.
7. Do you suspect your child has a hearing problem or vision problem?
*
Yes
No
If Yes to question 7, please describe
8. Which statement best describes your child's ability to move from one activity to another
*
Easily moves from one activity to another
Needs assistance to move from one activity to another
9. How does your child play/ interact best? (please check all that apply)
*
Independently
With another child
Small group
Large Group
Outdoors
Indoors
With Adults
Other
10. Do any of the following bother your child?
*
Noise
Texture (i.e. sand, water)
Lights
Touch (i.e. Hugs)
Smells
Other
11. Does your child wander, run away or bolt?
*
Yes
No
If yes to question 11, what situations precede this behavior?
12. Is your child able to do the following activities by him/herself?
*
Rows
Yes
No
If no please describe
Use the toilet
Eat or Drink
Walk/ move about
Wash hands
13. Does your child take medication?
*
Yes
No
If yes to question 13. what medications and are there any side effects
Is there anything else you would like to share about your child (i.e., allergies, diet, seizures, nosebleeds)?
*
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