Please indicate which school you are enrolling your child for the 2022-2023 school year:
*
Please Select
Cesar Chavez College Preparatory School K-5 (Mock Rd)
Educational Academy for Boys and Girls K-5 (Midland Ave)
Midnimo Cross-Cultural Middle School 6-8 (Loretta Ave)
Unity Academy High School 9-12 (Schrock Rd)
Student's Legal Last Name
*
Student's Legal First Name
*
Student's Middle Name
Gender
Female
Male
Student's Date of Birth:
*
-
Month
-
Day
Year
Date
Proof of Age
Please Select
Birth Certificate
Passport
I-9
Other
Social Security Number:
Ethnicity
*
American Indian/Alaskan Native
Asian/Pacific Islander
Black/African-American (Non-Hispanic)
Hispanic
Multiracial
Somali
White (Non-Hispanic)
Other
Student's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Parent/ Guardian Email
example@example.com
Has your student attended a public school?
Yes
No
Name of previous school attended
Previous School District
Dates at previous school
Current Grade
*
Based on your home address what school would your child attend
Does your child qualify or Special Needs Services? (IEP, Special Education) If, yes what type?
Has your child ever been suspended or expelled from another school district? If yes, when?
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Parent/Guardian Contact Information
Who has custody of this student?
*
Both Parents
Mother Only
Father Only
Guardian
Other
With whom does the student live?
*
Both Parents
Mother Only
Father Only
Guardian
Other
1st Parent/Guardian Information
*
First Name
Last Name
1st Parent/Guardian Information
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
1st Parent/ Guardian Language Spoken at home
Does the 1st parent/guardian speak English
Yes
No
Is the 1st Parent/Guardian willing to volunteer at the school?
Yes
No
Is the 1st Parent/Guardian Military?
Yes
No
1st Parent/ Guardian Employer
1st Parent/ Guardian Business Phone Number
Please enter a valid phone number.
Is 1st Parent/ Guardian available at work?
Yes
No
1st Parent/ Guardian Home Phone Number
Please enter a valid phone number.
1st Parent/ Guardian Cell Phone Number
*
Please enter a valid phone number.
1st Parent/Guardian Email Address
example@example.com
2nd Parent/Guardian Information
First Name
Last Name
2nd Parent/Guardian Information
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2nd Parent/ Guardian Language Spoken at home
Does the 2nd parent/guardian speak English
Yes
No
Is the 2nd Parent/Guardian willing to volunteer at the school?
Yes
No
Is the 2nd Parent/Guardian Military?
Yes
No
2nd Parent/ Guardian Employer
2nd Parent/ Guardian Business Phone Number
Please enter a valid phone number.
Is 2nd Parent/ Guardian available at work?
Yes
No
2nd Parent/ Guardian Home Phone Number
Please enter a valid phone number.
2nd Parent/ Guardian Cell Phone Number
Please enter a valid phone number.
2nd Parent/Guardian Email Address
example@example.com
Emergency Contact Information (Other than the parent/guardian)
One emergency contact is required. If you'd like to add more than 2 please contact the school once your child's application has been accepted.
1st Emergency Contact
*
First Name
Last Name
1st Emergency Contact Cell Phone #
*
Please enter a valid phone number.
1st Emergency Contact Home Phone #
Please enter a valid phone number.
1st Emergency Contact Business Phone #
Please enter a valid phone number.
2nd Emergency Contact Business Phone #
Please enter a valid phone number.
2nd Emergency Contact
First Name
Last Name
2nd Emergency Contact Home/Cell Phone #
Please enter a valid phone number.
2nd Emergency Contact Cell Phone #
Please enter a valid phone number.
How did you hear about Ed. Solutions
Please Select
Radio
TV
Friend
Newspaper
Employee
Billboard
Other
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Emergency Information Form
Page 1 of 2
Student Name
*
Student Address
*
School Attending
Insurance/ Medicaid Number
Student Social Security Number
Phone Number
*
Please enter a valid phone number.
Part I (To grant consent)
In the event we have made multiple attempts to contact parents/guardians and emergency contacts we will contact either Physician, Dentist or Preferred Hospital.
Parent/ Guardian Best Phone Number
Please enter a valid phone number.
2nd Parent/Guardian Name
2nd Parent/ Guardian Best Phone Number
Please enter a valid phone number.
Preferred Physician Dr.
Physician Phone Number
Please enter a valid phone number.
Preferred Dentist
Dentist Phone Number
Please enter a valid phone number.
Preferred Hospital
Please include any facts concerning the child's medical history including allergies, medications being taken, and any other physical impairments to which a physician should be alerted.
Today's Date
-
Month
-
Day
Year
Date
Signature for Emergency Medical Authorization
Part II (Refusal to grant consent)
Do not complete part II if you completed part I
Today's Date
-
Month
-
Day
Year
Date
Signature for Refusal of Consent
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Emergency Information Form Part 2
Part 2 of 2
Childs Name (Last, First, MI)
Student Date of Birth: (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Child's Spoken Language
Child lives with:
Mother
Father
Foster Parent
Guardian
Parent's Name (Last, First)
Address
Telephone Number
Please enter a valid phone number.
Alternate Number
Please enter a valid phone number.
Employer Name
Primary Care Physician
Physician Phone Number
Please enter a valid phone number.
Emergency Contact Number 1 (Name, Address, Phone Number)
Emergency Contact Number 2 (Name, Address, Phone Number)
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Media Interview & Photo Release
Authorization
Section 1
Student Name
Media Release Signature
Today's Date
-
Month
-
Day
Year
Date
Refusal for media & photo release
Do not fill out section 2 if you filled out section 1
Student Name
No Permission - Media Signature
Today's Date
-
Month
-
Day
Year
Date
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Parent Consent for Student Records Release
Please indicate which school is sending the records request:
Please Select
Cesar Chavez College Preparatory School K-5 (Mock Rd)
Educational Academy for Boys and Girls K-5 (Midland Ave)
Midnimo Cross-Cultural Middle School 6-8 (Loretta Ave)
Unity Academy High School 9-12 (Corporate Dr)
Previous School to receive request:
Student Name
Student Date of Birth
-
Month
-
Day
Year
Date
Student Address
Current Grade
Request for Records - Parent/ Guardian Signature
Today's Date
-
Month
-
Day
Year
Date
Parent/Guardian Name:
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Ohio Department of Education
Language Usage Survey
Student Name: ( First Name and Last Name)
Student Date of Birth: (mm/dd/yyyy)
/
Month
/
Day
Year
Date
1. In what language(s) would your family prefer to communicate with the school?
2. What language did your child learn first?
3. What language does your child use the most at home?
4. What languages are used in your home?
5. In what country was your child born?
6. Has your child ever received formal education outside of the United States?
Yes
No
If yes, how many years/months?
If yes, what was the language of instruction?
7. Has your child attended school in the United States?
Yes
No
When did your child first attend a school in the US? (Month)
When did your child first attend a school in the US? (Day)
When did your child first attend a school in the US? (Year)
Please share additional information to help us understand your child's language experiences and educational background.
Parent/Guardian Name
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Signature
Today's Date: (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Please indicate which School your child is enrolled
Unity Academy High School
Educational Academy for Boys and Girls
Cesar Chavez College Preparatory School
Midnimo Cross Cultural Middle School
Name
10 Digit Case Number
SIZE OF FAMILY Indicate the total number of individuals living in your household, including all adults and children
Total Monthly Household Income (Add lines 1 6)
Sign Here: X
Print Parent/Guardian Name
Last Four (4) Digits of Adult Social Security Number
I do not have a Social Security Number
Address
Home Phone
Email Address
example@example.com
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Upload Your Documents
Upload proof of child's age (Birth Certificate, Passport, I-9, or USCIS Document)
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Upload proof of address (Utility Bill or Lease)
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Upload Child's Shot Record
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Upload Social Security Card
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