Lumos Arts Academy Enrollment Application

Student Information

Are you a new or returning student to Lumos? *

New Student Returning Student

Student Name *

First Name Middle Name Last Name

Birth Date *

Month Day Year

Gender *

Male Female

Cell Number *

Area Code Phone Number

E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Racial/Ethnic Background *

White Black Hispanic American Indian Asian

What school year are you applying for? Example: 2018-2019 *

What school year are you applying for? *

What is the primary language spoken by the student? *

How did you hear about us? *

Please tell us about your student's artistic background and areas of interest in the Arts. Be as detailed as possible, including all artistic accomplishments. *

Please tell us about any service-oriented work your student has done. *

Other comments:

Parent/Guardian Information (if student is under 18 years old)

Parent Name *

First Name Last Name

Home Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

Work Number

Area Code Phone Number

Work Extension Number

E-mail *

Parent Name

First Name Last Name

Cell Number

Area Code Phone Number

E-mail

As a parent member of our Lumos Community, what talents/gifts/abilities can you contribute to OUR school? *

Other comments:

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Email address

Alt. Phone Number

Area Code Phone Number

Last school attended, city and state *

Grade entering in 2019-2020 (K-12) *

The last year your student attended school *

Does your student have or have they ever had a medical or educational diagnosis? *

Is your student currently enrolled in a Special Education program? (including Speech) *

Does your student currently have or have they ever had an IEP or 504? *

If yes, what is the name of the school where the IEP/504 was obtained?

If yes, when will these documents (504/IEP) expire?

Informed Consent and Acknowledgement

No student will be considered for enrollment until all necessary documentation is received and student eligibility is verified. Misrepresentation or omission of facts on this application may result in denial or nullification of enrollment.

Student also agrees that he/she will meet the contact requirements set forth by mentor/teacher/learning plan. Communication between the student and mentor/teachers/staff is imperative to the student's success.

By checking the box below I indicate that the information contained in this application is true. I also understand that my student is not enrolled in Lumos Arts Academy until such has been confirmed by an authorized member of Lumos Arts Academy.

No student will be considered for enrollment until all necessary documentation is received and student eligibility is verified. Misrepresentation or omission of facts on this application may result in denial or nullification of enrollment.

By checking the box below I indicate that the information contained in this application is true. I also understand that my student is not enrolled in Graduation Solutions until such has been confirmed by an authorized member of Graduations Solutions.

Choose one *

I agree I disagree

Media Release

I, the undersigned, do hereby grant or deny permission to Lumos Arts Academy to use the image of myself/my child as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials, videos and digital images such as those on our website.

No student will be considered for enrollment until all necessary documentation is received and student eligibility is verified. Misrepresentation or omission of facts on this application may result in denial or nullification of enrollment.

By checking the box below I indicate that the information contained in this application is true. I also understand that my student is not enrolled in Graduation Solutions until such has been confirmed by an authorized member of Graduations Solutions.

Choose one *

Grant unrestricted permission to use my/my child's image Deny permission to use my/my child's image at all

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Anything else you would like us to know?

Parent/Student over 18 Signature *

Enrollment Application

Educational Information