LifeGate Academy Enrollment Form

LIFEGATE ACADEMY ENROLLMENT FORM
School Year*
Public School District*
Section I. TO BE COMPLETED BY PARENT OR GUARDIAN
Student Name*
Home Phone*
Home Address*
City, State*
Zip Code*
Date of Birth*

MonthDayYear
Date
Grade*
Parent or Guardian's Name*
Home Phone*
Email
example@example.com
Home Address*
City, State*
Zip Code*
Private School of Enrollment
School Phone*
Address
City/State
Zip Code
Date*

MonthDayYear
Date
Signature*

Clear
** Section II. TO BE COMPLETED BY CHURCH SCHOOL **
Church School of Enrollment
School Phone
Address
City/State
Zip Code
Date of Student Enrollment

MonthDayYear
Date
for School Year
Date

MonthDayYear
Date
Signature of School Administrator

Clear
Section III. CONSENT FOR NOTIFICATION OF STUDENT WITHDRAWAL
I hereby give prior consent to the administrator of LifeGate Academy Church School to notify the public school superintendent should the above named student cease attendance at said School.
Date*

MonthDayYear
Date
Signature of Parent or Guardian*

Clear
Parent/Guardian Email*
example@example.com
Should be Empty: