Liberty Academy Elementary Student Application
Kindergarten - 5th Grade
Student Information
Please Fill out one application per child
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
*
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
*
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
*
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
*
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
Information
Parent Full Name
Relationship to student
Primary Phone Number
Secondary Phone Number
Email
Home Address
Required Authorized Contacts for Pickup
*
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
Authorized Contacts for Pickup #2
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
Follow Up Information
Please fill out all information
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.
School Year Applying to
*
Please Select
2023-2024
2024-2025
2025-2026
2026-2027
2027-2028
2028-2029
2029-2030
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
*
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
I consent to receiving text messages and E-mail from Liberty Academy for application and enrollment purposes.
*
Yes
Submit
Submit
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