Summer School Application Form

Summer School Application Form

Summer
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Choose not to identify
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade Level
School Currently Attending
Parent/Guardian's Information
Parent/Guardian's Name - Primary

First NameLast Name
Relationship to Student
Email
example@example.com
Phone Number
Please enter a valid phone number.
Parent/Guardian's Name - Secondary

First NameLast Name
Relationship to Student
Email
example@example.com
Phone Number
Please enter a valid phone number.
In case of emergency, who should we contact if neither parent/guardian is available? Please answer the fields below:
Emergency Contact Person

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
Is there anyone besides the parents/guardians and emergency contact who is allowed to pick up your student or whom we are allowed to speak with about your stdent (e.g. if they ask a question about the student's schedule)? By providing the names below, you are giving us explicit permission to speak with and release the students to these individuals:

Full NameRelationship to Student
Please enter a valid phone number.
Subject and Services

Summer school is a time for students to retake classes they failed (credit recovery), or for students to get caught up or get ahead by taking additional classes (course for credit). Select which service(s) you are interested in.
Select all that apply

Credit Recovery (half credit)Credit Recovery (full credit)Course for Credit (half credit)Course for Credit (full credit)
Please specify which subject(s)/class(es) your student needs to complete (e.g. credit recovery for second semester of Algebra I or full credit of English II)
Please include any travel/vacation dates over the summer we need to avoid to help facilitate scheduling. The summer semester starts May 27 and ends August 1.
Health History

This form contains important information we will need to help ensure the health and safety of your student. It is required to be completed before the student's first day at Gateway Academy.
If the student has any allergies, please list them below:
Do any of these allergies require immediate medical attention such as administration of epinephrine and/or a trip to the ER? If yes, please provide specific details on how the reaction manifests and what should be done to offer immediate treatment.
Does the student currently take any medications? If yes, please list them below:
Does the student have any medical conditions that you would like to declare?

Medications: Our staff keeps some non-prescription medication on hand for minor medical issues such as a headache, heartburn, etc. Please indicate whether your student is allowed any of the below medications

	Yes or No
Ibuprofen (e.g. Advil)
Acetaminophen (e.g. Tylenol)
Naproxen Sodium (e.g. Aleve)
Antacids (e.g. Tums)
Bendaryl

Does your student have any psychological or mental health diagnoses you would like to declare? (We ask for this information so that our staff might know how best to serve your student)
Legal Alerts
Are there any legal concerns that our staff should be aware of to help ensure your student's safety? (e.g. custody issues, restraining orders, etc). If yes, please explain.
Guardian Release

Initial each section to show that you understand, agree, and acknowledge the following:

	Initials
Gateway Academy does not provide insurance coverage for students enrolled in its programs against expenses of accident, injury, or illness suffered while enrolled. Enrollment and participation is the sole risk of students and their guardians.
In the event that the enrolled student requires emergency treatment or hospital admission, and circumstances do not allow for timely contact of the undersigned by Gateway Academy official, Gateway Academy officials are hereby authorized to take actions they deem necessary for the emergency medical treatment of students.
Gateway Academy and its officials, teachers, etc, are fully released from any and all liability for loss, damage, illness, or injury suffered by students when enrolled. Any and all expenses associated with section 2 above shall be the sole responsibility of the guardian, and the undersigned indemnifies Gateway Academy, its officials, teacher, etc, and holds them harmless against claims of suits made of brought by anyone because of such injury, illness, or loss.
Gateway Academy and its officials, teachers, etc. shall not be responsible for students both before and after scheduled classes.
I understand that Gateway reserves the right to take pictures of my child to use for internal and school purposes.
I understand that there is no guarantee of ongoing enrollment at Gateway Academy. If my student does not meet attendance requirements or conduct expectations, or it is discovered that relevant information has not been provided to school officials, my student may be immediately expelled from Gateway Academy. Under such circumstances, no grades or credits will be awarded, the registration fee will not be returned, and I will be responsible for any remaining tuition balance for my student.

Gateway Acknowledgement Statement

To be completed by perspective students:

Dear student, please review the following commitments with your parents and initial to show that you agree to abide by these expectations while attending Gateway Academy:

	Intials
Gateway Academy is a safe and affirming space for every one, and no aggression, bullying, or harassment of any kind will be tolerated.
Gateway Academy is drug, alcohol, and nicotine-product (including all vapes) free. Even if I can legally purchase and/or ingest a prohibited item, I will not have it anywhere on campus (including the parking lot).
Gateway Academy serves people of all ages, and I will wear appropriate clothing and use appropriate language
Gateway Academy needs me to be here in order to learn, so I will do my best to be present and on time. I understand that tardies will count toward my total absences.
Gateway Academy needs me to be mentally present as well, so I will keep potentially distracting electronic devices silenced/off and put away in a bag or locker during class.
Gateway Academy requires that I complete any assigned work and maintain academic excellence by avoiding plagiarism including but not limited to work created or generated by A.I.
I acknowledge that I have read and understand all of Gateway's policies and procedures and that failure to abide by them may result in disciplinary action, up to and including expulsion.

Date Signed

MonthDayYear
Date
Parent/Guardian Signature

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Summer School Application Form

Parent/Guardian's Information

Subject and Services

Health History

Legal Alerts

Guardian Release

Gateway Acknowledgement Statement