PLUM's St. Howard Academy School Enrollment Form 2025-2026

PLUM's St. Howard Academy School Enrollment Form 2025-2026

"St. Howard's Academy"
Applicant Information
1st. Child's Name*

First NameMiddle NameLast Name
2nd. Child's Name*

First NameMiddle NameLast Name
3rd. Child's Name*

First NameMiddle NameLast Name
4th Child's Name*

First NameMiddle NameLast Name
5th Child's Name*

First NameMiddle NameLast Name
6th Child's Name*

First NameMiddle NameLast Name
1st. Child's Gender*
2nd. Child's Gender*
3rd. Child's Gender*
4th Child's Gender*
5th Child's Gender*
6th Child's Gender*
Religion
1st. Child's Date of Birth*

MonthDayYear
Date
2nd. Child's Date of Birth*

MonthDayYear
Date
3rd. Child's Date of Birth*

MonthDayYear
Date
4th. Child's Date of Birth*

MonthDayYear
Date
5th. Child's Date of Birth*

MonthDayYear
Date
6th. Child's Date of Birth*

MonthDayYear
Date
1st. Child's Last 4 of SSN #*
2nd. Child's Last 4 of SSN #*
3rd. Child's Last 4 of SSN #*
4th. Child's Last 4 of SSN #*
5th. Child's Last 4 of SSN #*
6th. Child's Last 4 of SSN #*
Email*
example@gmail.com
Parent/Guardian Contact Phone Number*
Please enter a valid phone number.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Name (if only 1 type NA)*

First NameLast Name
Marital Status*
Parent/ Gurdian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Utility Bill
Proof of Income
Birth Certificate
Proof of Counselor, IDEA-504, OR IEP from Public School
My child needs to be pick-up for school each morning and dropped after school each day.*

Contact In case of Emergency
Name*

First NameMiddle NameLast Name
Mobile Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*

Medical Information
Does your child have special instructions for medical treatment? If yes, please explain including the medication your child is taking, and the dosage amount. *
Does your child have or had Asthma, Kidney Disease, Diabetes, Heart Murmur, Seizures, Hay Fever? Please explain below?*
Does your Child have any Medically diagnosed disability or Mental Health Challenge?*
Your Child's Doctor

First NameLast Name
Your Child's Doctor Phone Number
Please enter a valid phone number.

Liability Wavier
I am voluntarily allowing my children to participate and attend this school, and in its physical exercise that can be strenuous and subject to risk of serious injury during recreational activity and nonrecreationay. PLUM’S St. Howard’s Academy request that you consult with your child physician before participating in these activities. You agree that by participating in these physical exercise sessions or personal training activities, is at your own risk. I recognize that exercise is not without some risk to the musculoskeletal system (e.g. sprain, strain) and cardiorespiratory system (e.g. dizziness, fainting, abnormal heartbeat, discomfort in breathing, abnormal blood pressure response, and in rare instances, heart attack or stroke). I acknowledge that not all risks can be known in advance.

I HEREBY, for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, “Releasor,” “I” or “me”, which terms shall also include Releasor’s parents or guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in the Activity.

I HEREBY release and forever discharge PLUM St. Howard’s Academy, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively “Releasees”), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity and School.

I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney fees and any related costs.

I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize PLUM’s St. Howard’s Academy to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel.

I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. In the event that any damage to equipment, field or facilities occurs as a result of my or my family’s or my agent’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any such actions of neglect or recklessness. Both participant and PLUM’s St. Howard’s Academy agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted altering or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.
I Agree to the Liablity wavier statement*

CONSENT

I, the undersigned, hereby declare and affirm that:

I am the parent/legal guardian of the youth named above (hereinafter referred to as "Child"), who is under my care and responsibility.

I hereby consent and give authority to the participation of my Child in the scheduled youth activities of the School, and all other activities which is supervised and customarily associated with its youth programs.

I hereby declare and affirm that my Child is physically fit to take part in the Schools's activities and my Child has no known illness or adverse medical condition that would render him/her unfit to participate herein, other than the information specified in the medical information above.

I shall immediately advise the organizers in writing, should I discover any illness, adverse medical condition, or any other physical defect that would render my Child unfit to participate in the recreational and sporting activities of the School.

I shall notify the organizers immediately in writing, in case I revoke my consent to the School for this event.

Authorization for Medical Treatment

I understand that in case of medical emergencies involving my Child, I shall be notified right away. In case any of my provided contact information is unreachable, I authorize the School to call the doctor indicated above. In case that the doctor is not available, I authorize the school to call any doctor to provide the necessary medical attention to my child.

I understand that the School shall not be responsible, and shall be reimbursed, for any medical expenses incurred by them over this authorization.
I Agree to the Medicial Treatment and Consent Statement.*
PHOTO CONSENT AND WAVIER

I consent to St. Howard’s Academy use of my child and my photographs .

I authorize St. Howard’s Academy to take my child’s photographs

I authorize St. Howard’s Academy to use my photos on Facebook, Linkin, Instagram, and other social media platforms.

I authorize St. Howard’s Academy to edit, alter, copy, or distribute the photos for social media advertising and marketing.

I authorize St. Howard’s Academy to edit, alter, copy, or distribute the photos for social media advertising and marketing.

I agree that I will not receive any monetary compensation for usage of my photographs in social media platforms.
I Agree to the Photo Consent and Waiver Statement*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Parental Information
Name of Mother*

First NameMiddle NameLast Name
Mother's Job/Contact Phone*
Mobile Number*
Address of Mother*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Father*

First NameMiddle NameLast Name
Father's Job/Contact Phone*
Mobile Number*
Address of Father (if not the same as above)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full Name of Applicant*

First NameLast Name
By signing this form, you accept this as a legally binding contract between you the legal parent or guardian and PLUM's St. Howards Academy, you agree to apply for the Education Freedom Account (EFA), completing all required applications and retrieving all necessary documentation, as well as submitting all required forms to apply for EFA to use the funds towards your tuition waiver at St. Howard's Academy. You Also agree to apply all available funding and scholarships available to help cover the cost of tuition with St. Howard's Academy. You also agree and understand that by signing this application your child is enrolled for the quarter of the date of this application that they are enrolled. Failure to attend, without completing the proper withdrawal form with our school, before their first schedule instructional day of attendance will result in you being legally and financially responsible for the total quarter cost of enrollment at PLUM's St. Howard's Academy that your child or children were enrolled. if you do not or not able to apply the EFA funds towards the tuition cost here at PLUM's St. Howard's Academy you are responsible for paying this amount out of pocket. The total out of pocket cost per quarter $5,500.00 for the day and afterschool program. Total Tuition cost is $20,000.00 dollars a year, $12,000 towards attendance in the day program, $8,000.00 for the after-school program. Applicant's Legal Gurdian Signature*

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PLUM's St. Howard Academy School Enrollment Form 2025-2026

Applicant Information

Application Details

Educational Background

Contact In case of Emergency

Medical Information

Liability Wavier

Parental Information