LifeWise Academy Permission Slip

Student Registration for LifeWise Pine Richland
In addition to their regular classes, parents have the option of enrolling their children in LifeWise Academy.
- LifeWise Academy is a non-denominational, Bible-based released time religious instruction program with emphasis on character education
- Students attend classes during the day on a schedule that fits the public school classroom rotation.
- Children will attend Lifewise classes during Explore Time.
- Students will travel with Lifewise chaperones to and from their LifeWise classes
- Classes will take place for 4th & 5th grade on Thursdays and 6th grade on Tuesdays
- LifeWise classes are subject to change days of the week if needed. This will be communicated.
- For more details, visit our website at lifewise.org/pinerichlandpa
Note: This permission slip will remain in effect as long as the child is enrolled with the local public school.
Student information
Name*

First NameLast Name
Birth Date *

MonthDayYear
Grade for 23-24 school year*
Classroom Teacher
*If known
Parent information
Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any student health concerns (epi pen, asthma etc) or food allergies we should be aware of:
Are there any custody arrangements we should be aware of? If yes, please explain below.
I consent to the photography or video of my student while in LifeWise, for promotional purposes.*

YesNo
Signature

Clear
Should be Empty:

Student Registration for LifeWise Pine Richland

Student information

Parent information