1251 Learning Essential Academy Enrollment Form

1251 Learning Essentials Academy: Enrollment Form
Student Information
Student Name*

First NameLast Name
Student Date of Birth*

MonthDayYear
Date
Student T-Shirt Size*
Current School or Homeschool Program*
Please provide a detailed response. For example, if you use several programs for homeschooling, please explain which programs are used for each subject.
Student Interests*
Learning Strengths and Challenges*
Allergies, Medical Conditions, or Special Diets*
Enrollment and Pricing
Please select your preferred enrollment plan.*
Please select your preferred enrollment days.*

Monday- Friday ( 5-Days)Monday, Wednesday, Friday (3-Days)
Please select your preferred payment plan.*
Authorization to Leave Unsupervised
Please select your preference below. If you select YES, please note that this authorization grants permission for this child to leave Program without adult supervision. If permission is granted, Program is not responsible for your child once they leave the premises.*

YES - My child is authorized to leave the premises without adult supervision.NO - My child is NOT authorized to leave the premises without adult supervision.
If you selected YES above, please indicate the locations that your child is allowed to go.
CPR and First Aid
By checking this box, I authorize the staff of Program who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached and a delay would be dangerous to the health of my child, I hereby authorize the program to transport my child to a medical care facility and to secure necessary medical treatment for my child, including, but not limited to, an epinephrine auto-injection for suspected exposure to a life threatening allergen.*

I have read the above and agree.
Media Release
Promoting the activities and accomplishments of our students throughout the year gives our community the opportunity to see the great things taking place in our program. Therefore, photos and videos of students may be taken in connection with program activities or events for printed/online publications, newsletters, website stories, social media, and other publications.*

I DO give permission for my child's photo/video to be taken.I DO NOT give permission for my child's photo/video to be taken.

Student Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
How many parents/guardians would you like to add to your child's enrollment profile?*
Parent/Guardian 1
Name*

First NameLast Name
Email*
example@example.com
Phone*
Please enter a valid phone number.
Parent/Guardian 2
Name

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.
Authorized Pickups

If you would like to authorize additional individuals (other than the parents/guardians to pick-up your child, please list them below.
How many additional authorized pickups would you like to add to your child's enrollment profile?*
Authorized Pickup 1
Name

First NameLast Name
Phone
Please enter a valid phone number.
Relation
Example: Grandfather, Neighbor, Family Friend
Authorized Pickup 2
Name

First NameLast Name
Phone
Please enter a valid phone number.
Relation
Example: Grandfather, Neighbor, Family Friend
Authorized Pickup 3
Name

First NameLast Name
Phone
Please enter a valid phone number.
Relation
Example: Grandfather, Neighbor, Family Friend
Authorized Pickup 4
Name

First NameLast Name
Phone
Please enter a valid phone number.
Relation
Example: Grandfather, Neighbor, Family Friend

Terms and Conditions

This Contract is between 1251 Learning Essentials Academy (hereinafter the “Program”) and the parent(s) or legal guardian(s) (hereinafter referred to as “Parent,” which term includes the singular or plural, as applicable) of the student listed above (hereinafter “Student”). All persons signing this Contract are jointly and severally liable for the tuition and fees set forth herein. Parent’s signature and/or initials on this Contract evidence Parent’s understanding and agreement to the terms of this Contract, as follows.
HOURS OF OPERATION AND CALENDAR

Program is open Monday- Friday 7:30-2:30, consistent with the calendar listed on the Program website. Student is not permitted to remain at Program after closing time. The Program is not responsible for the care or supervision of students beyond program closing time.

COMMITMENT
The Program has a one-semester commitment. After the one-semester commitment, the Parent may withdraw the Student from the program at any time, for any reason, with thirty (30) days' written notice.

REFUNDS
Due to Program's Open Door Policy, Parents are charged the annual or monthly payment fee regardless of Student attendance. As such, no credits, prorated discounts, makeup days, or refunds are provided for sick days, vacation days, calendar holidays, calendar professional development days, half-days, or other missed days.

LATE PAYMENTS & NONPAYMENT PENALTIES
If payments are not received by the 5th of the month, a $25 late fee may be added to the invoice. If payments are not received by the 10th of the month, the Student's enrollment will be placed on a suspension until the account balance is paid in full. Student will not have access to their program during this suspension period, and no refunds or credits will be given in the event of a suspension due to nonpayment. After one month of suspension due to nonpayment, the Student's enrollment may be terminated at the Program’s sole discretion. In the event of consistent late payments or nonpayments, the Program reserves the right to charge the credit card on file.

LATE PICK-UP FEES
If Parents expect to pick-up the Student after Program closing time, Parent should communicate as soon as possible. Program reserves the right to charge a late fee of $1.00 per minute after closing time. If a child is not picked up by 3:00 P.M., Program will call an authorized pick-up person listed on the Student's enrollment form. Program is required to call the Department of Child Safety if Student remains at Program after 5:00 P.M. and staff cannot reach the Student's family or an authorized individual. Parents who are late on a consistent basis may be subject to dismissal from Program.

SUSPENSION AND TERMINATION
The Program reserves the right to suspend or terminate any student from its program, in its sole discretion. Some reasons a student may be discharged include misconduct, inappropriate behavior by either the student or a family member, any behavior by either the student or family that violates any Program policy, and non-payment. Should the Student be involuntarily discharged or expelled from the program, the Parent forfeits all payments for tuition.

CONSENT FOR OBSERVATION OF STUDENTS
Parent understands that from time to time, third parties who are neither Program staff nor parents of other students may visit Program while the Student is there and observe my child, without interacting with Student and without Student being identified to such third parties. Parent understands that there are benefits to allowing such observations. For example, this allows members of the community, such as prospective students and their families, to learn about the program and tour the facility. It also allows the Program to interact with prospective community partners which may provide services to the Program. By signing below, Parent gives general informed consent to allow this type of non-interactive, de-identified observation of the Student.

MEDIA RELEASE
Unless opted out in the above enrollment form, Parent represents and acknowledges that Parent is/are the parent(s) or legal guardian(s) of the Student identified above (“Student”) with legal authority to agree to the terms and conditions of this Media Release. By signing below, Parent gives the Program, and any individual or entity acting for or on behalf of the Program, permission to take and to use the Student’s photograph, video, audio recordings, or other testimonials of the Student and/or the Student’s name, image, voice or likeliness (collectively, the “Materials”) for the Program's website, social media (Twitter, Facebook, LinkedIn, Instagram, etc.), video presentations, press releases, articles, brochures, newsletters, audio-visual presentations, websites and other educational, marketing, or promotional materials (collectively, “Marketing”). Program shall be the sole owner of the Materials, free from any rights and permission by me or the Student, with the right to publish or otherwise use or disclose the Materials, and neither I nor the Student will have any right to compensation, notification, or review in connection with Program’s use or disclosure of the Materials. Parent hereby agrees to release and hold harmless Program and its affiliates, and its employees, agents, assigns and successors from all demands, actions, causes of action, suits, damages, claims and liabilities, of every name and nature, both in law and in equity, including, without limitation, any claims for defamation or invasion of privacy under state and/or federal laws, in any way related to the taking, use or distribution of any such photographs as defined and described above. This consent is voluntary. To opt out of this media release, please indicate in the enrollment form above.

FERPA RECORD RELEASE
By signing below, Parent acknowledges that the Family Educational Rights and Privacy Act (FERPA) affords parents and students who are 18 years of age or older ("eligible students") certain rights with respect to the student's education records. These rights are:

The right to provide written consent before the school discloses personally identifiable information (PII) from the student's education records, except to the extent that FERPA authorizes disclosure without consent.

One exception which permits disclosure without consent is disclosure to school officials with legitimate educational interests. A school official is a person employed by the school as an administrator, supervisor, instructor, or support staff member (including health or medical staff and law enforcement unit personnel) or a person serving on the school board. A school official also may include a volunteer or contractor outside of the school who performs an institutional service of function for which the school would otherwise use its own employees and who is under the direct control of the school with respect to the use and maintenance of PII from education records, such as an attorney, service provider, auditor, medical consultant, or therapist; a parent or student volunteering to serve on an official committee, such as a disciplinary or grievance committee; or a parent, student, or other volunteer assisting another school official in performing his or her tasks. A school official has a legitimate educational interest if the official needs to review an education record in order to fulfill his or her professional responsibility.

AUTHORIZATION
By signing below, Parent represents and acknowledges that Parent is/are the parent(s) or legal guardian(s) of the student identified above (“Student”) with legal authority to agree to the terms and conditions of this Authorization. Parent consents to the Student’s participation in the program operated by Program, including his/her/their attendance at Program. To ensure that Program is fully equipped to support Student, Parent agrees to share Student's academic data, including but not limited to: academic programs, curriculum, and gradebooks. Parent authorizes Student's school or academic program to share any academic data with Program.

Parent forever releases, acquits, discharges, and covenants to hold harmless Program and its agents, employees, officers, directors, successors, and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses, and compensation on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries or property damage which Parent may now have or may hereafter have that result from or relate to the Student’s participation in the Program or engagement in related activities unless such injury, loss, or damage is due to the gross negligence of Program. “Related activities” include but are not limited to activities sponsored by, carried out by, or otherwise involving Program or a related third-party, such as after-hour or weekend program events, field trips, excursions, and community service activities. Notwithstanding anything contained in this Authorization to the contrary, no personal liability shall accrue against any individual officer, director, member, partner, fiduciary, employee, agent or representative of Program, or any heir, personal representative, successor or assign of the foregoing with respect to any matters arising under this Authorization.

Parent assumes liability for and shall indemnify and hold harmless Program from and against any and all losses, damages, penalties, liabilities, claims, actions, suits, costs, and expenses, including reasonable attorney’s fees, whether in law or in equity, of any kind or nature whatsoever, imposed upon, incurred by, or asserted against Program in any way directly or indirectly relating to or arising out of any negligent or other wrongful act or omission of the Student. The provisions of this paragraph shall survive the termination of Student’s participation in the Program.

In signing this Authorization, Parent acknowledges and represents that Parent has read the foregoing Authorization, understands it, and signs it voluntarily. Parent executes this Authorization for full, adequate, and complete consideration. Parent understands that Parent is permanently giving up rights, including, but not limited to, the right to sue. Parent hereby asserts that participation is voluntary and that Parent knowingly assumes all risks. Parent has carefully read this agreement, has carefully considered it, and attests that Parent fully understands and knowingly and voluntarily accepts its terms in their entirety and without reservation, including the release of all known and unknown claims.
By signing below, Parent acknowledges that this Agreement/Contract is between Program and the undersigned Parent to enroll Student at Program. The parties agree that this agreement may be electronically signed and agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity and admissibility.*

Powered by Jotform SignClear

Family Handbook
Type a question
Parent acknowledges that Parent has received, reviewed, understands, and agrees to comply with the policies set forth in the Program's Student & Family Handbook, including, but not limited to, Program’s Code of Conduct. Parent acknowledges that Parent has reviewed Program’s conduct expectations with Student who will be participating in the Program, and that Student understands and agrees to abide by those expectations.

Powered by Jotform SignClear

Registration Fee

My Products

Enrollment Registration Fee

$150.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

1251 Learning Essentials Academy: Enrollment Form

Student Information

Enrollment and Pricing

Authorization to Leave Unsupervised

CPR and First Aid

Media Release

Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian 2

Authorized Pickups

Authorized Pickup 1

Authorized Pickup 2

Authorized Pickup 3

Authorized Pickup 4

Terms and Conditions

Family Handbook

Registration Fee