Gateway Academy Application Form

5500 Maryland Way, Suite 110
Brentwood, TN 37027
Telephone (615) 377-2929
School Application Form

Thank you for considering Gateway Academy for your student’s education. You may submit this application at any time; however, it must be completed in full before your student can be considered for enrollment. The application process relies upon collection of information about your student from other sources. Please note that we will consider mid-semester enrollments on a case-by-case basis depending upon the student’s individual circumstances and Gateway availability. There is a non-refundable application fee of $50.00 that will be collected at the time of enrollment.
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
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.
If divorced, who has legal custody? (Please specify physical & educational custody rights)

JointFull Custody
For full custodial parent, please specify name and rights
Names of Stepparents if Applicable:
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.
Relationship to Student
Responsible Party for Payment of Tuition & Fees:
Full Name
Relationship to Student
Phone Number
Please enter a valid phone number.
Email
example@example.com
How did you hear about out program?

School Information
Has this student previously attended Gateway Academy?
Most recent school or home school umbrella attended:
Describe your student’s academic strengths:
Describe your student’s academic challenges:
What are the plans for this student next year?
Does your student have an IEP, learning plan, accommodation plan, or other special services inplace? If so, please provide diagnosis and describe.
Has your student ever skipped or repeated a grade? If so, please explain.
Has your student ever had excessive absences or been truant from school? If so, please explain.
Reason for Leaving Current School:
Were there discipline problems?
Was the student asked to leave or expelled?
If you answered yes to either of the above questions, please explain.
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 student (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
School History: Please list all schools attended and for what grades

Parent/Guardian Consent to Release Academic Information
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Contact Name
School Name
Dates Attended
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Release of Information

The student named above is applying for entry into Gateway Academy at the Learning Lab, a private school in Middle Tennessee. To help us in our admission process, we require pertinent educational information from the above named student’s previous school. This release form , when signed by the parent or legal guardian, serves as your authorization to release this student’s records and allow verbal communication between this party and Gateway Academy at the Learning Lab. This information will be used to make decisions relating to the student’s continuing educational needs.
Parent/Guardian Consent

I hereby authorize Gateway Academy at Learning Lab to obtain records from and engage inconversation with the above named school pertaining to academic record and educationalinformation of the above named student, and grant permission to the school to release thisinformation. This written consent is valid for one year from the date below , or until a writtenrequest to cease is presented. I understand that I may withdraw this written consent at any time.
Parent/Guardian Signature

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Date

MonthDayYear
Date

Parent/Guardian Consent to Release Counseling Information
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Contact Name
Counselor/Therapist Name
Date of Last Visit
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Release of Information

The student named above is applying for entry into Gateway Academy at the Learning Lab, a private school in Middle Tennessee. To help us in our admission process, we require certain information from third parties that have knowledge of the above named student’s educational, medical and/or family background. This release form, when signed by the parent or legal guardian, serves as your authorization to release this student’s records and allow verbal communication between this party and Gateway Academy at the Learning Lab. This information will be used to make decisions relating to the student’s educational needs.
Parent/Guardian Consent

I hereby authorize Gateway Academy at Learning Lab to obtain records from and engage inconversation with the above named professionals pertaining to current and previous testing,counseling and their services provided to my student, and I grant permission to the provider torelease this information. This written consent is valid for one year from the date below, or until awritten request to cease is presented. I understand that I may withdraw this written consent at anytime.
Parent/Guardian Signature

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Date

MonthDayYear
Date

Parent/Guardian Consent to Release Information from Third Party
Student Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Contact Name
Services Provided
Date of Last Visit
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Release of Information

The student named above is applying for entry into Gateway Academy at the Learning Lab, a private school in Middle Tennessee. To help us in our admission process, we require certain information from third parties that have knowledge of the above named student’s educational, therapeutic, medical, and/or family background. This release form, when signed by the parent or legal guardian, serves as your authorization to release this student’s records and allow verbal communication between this party and Gateway Academy at the Learning Lab. This information will be used to make decisions relating to the student’s educational needs.
Parent/Guardian Consent

I hereby authorize Gateway Academy at Learning Lab to obtain records from and engage inconversation with the above named third party pertaining to current and previous educationaland therapeutic information and grant permission to the provider to release this information. Thiswritten consent is valid for one year from the date below, or until a written request to cease ispresented. I understand that I may withdraw this written consent at any time.
Parent/Guardian Signature

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Date

MonthDayYear
Date

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 (food and/or medication), 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? In the unlikely event of a medical emergency, First Responders will need a comprehensive list of all medications the student takes regularly. If yes, please list them below along with dosage:
Does the student have any diagnoses of chronic (physical) medical conditionsthat require constant attention? Please describe thecondition(s) and their impact on the student's school day:

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 this student have any psychological diagnoses for which they are being treated with medication and/or counseling? (We ask for this information so that our staff will know how to best serve your student) If yes, please list the diagnoses and describe their severity.
Other Information:
Has your student ever had a major surgery?
Has your student ever been hospitalized for any reason?
Does your student have any specialized health needs?
Does your student take any medication on a regular basis?
Has your student ever had a traumatic experience?
Has your student ever received counseling?
Has your student ever been arrested or had any involvement with the law?
If yes to any of these above, explain:
Immunization Policy

We are committed to providing students who attend Gateway Academy with a rewarding and, above all, safe learning environment. That is why we require students to follow the Tennessee Department of Public Health's immunization requirements. Every student enrolled in any class at Gateway Academy whether full time or part time—must have a Tennessee Department of Health Certificate of Immunization Form on file. Out of state forms will not be accepted. If you have a religious or medical exemption, please contact the school director.

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.
Staying "In the Loop"

Our teachers send parents/guardians weekly updates regarding student progress. Some parents findit helpful to include other individuals in these updates, such as therapists, tutors, or othercaregivers. Please list the names and email addresses of anyone other than the parents you wouldlike to receive these updates.
Name & Relationship to StudentEmail
Name & Relationship to StudentEmail
Name & Relationship to StudentEmail
Leaving Campus During the School Day (Seniors Only)
Seniors have the privilege of leaving school grounds during lunches or study halls. This privilege maybe revoked at any time at the discretion of school administration. To be eligible for this privilege, the following minimum requirements must be met:

● Signed parent permission.
● Attendance rate of 95% or higher.
● No disciplinary concerns within the past 45 days.
● No class grade below a C for the most recent report card.
● No signicant academic concerns for the current grading period.

Students are expected to return on time from any off-campus excursion. Students with vehicles are expected to park close to the building. Students are not allowed to leave the building during the passing period in between classes.
If this student meets the above mentioned criteria, do they haveyour permission to leave school during lunch or study hall?
If this student will be driving to school, list the year, make, model, and license plate number of their vehicle:
Parent/Guardian Consultation Consent

Gateway Academy faculty and administration are going to do what is in the best interests of your child, which will include consulting with other members of the Gateway Academy and Learning Lab team even if they do not work directly with your student.

Parent Expectations
My major goals for my student for the upcoming school year are:
Homeschool Consent

If you are only partially enrolling in Gateway Academy for a specific class or classes and use a Homeschool Umbrella for all other classes, please complete the below portion:
Name of Homeschool Umbrella:
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 Gateway will use images of my child on social media, Gateway website, marketing literature, and news reports/articles. If there are any legal issues with my child's image being used, I understand it is my responsibility to communicate that to the Director prior to my student's first day of school.
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.
I have been provided with a copy of Gateway Academy’s Student and Parent Handbook. Both my child and I have read and understand the policies outlined in that document.

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.

I desire to have my student enrolled at Gateway Academy for the school year or semester beginning in Month blanks Year blank
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
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School Application Form

Parent/Guardian's Information

School Information

Parent/Guardian Consent to Release Academic Information

Release of Information

Parent/Guardian Consent

Parent/Guardian Consent to Release Counseling Information

Release of Information

Parent/Guardian Consent

Parent/Guardian Consent to Release Information from Third Party

Release of Information

Parent/Guardian Consent

Health History

Other Information:

Immunization Policy

Legal Alerts

Staying "In the Loop"

Leaving Campus During the School Day (Seniors Only)

Parent/Guardian Consultation Consent

Parent Expectations

Homeschool Consent

Guardian Release

Gateway Acknowledgement Statement