LEAD Academy

LEAD Academy - Application
source
language
parent_relationship
preferred_contact
leadid
schoolid
How did you hear about us?*
School Year?*
Grade applying for?*

Student Information
Student Name*

First NameLast Name
Gender

MaleFemaleWould Rather Not StateOther
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity*
Birth-Date*

MonthDayYear
Date
Country/State of Birth*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Family Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Parent or Guardian Employer
Parent / Guardian Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does the student have any siblings who currently attend LEAD Academy?*

YesNo

Miscellaneous Information
Which school did the student attend last year?*
Does the student require any physical accommodations?

YesNo

Emergency Contact Information*

	Name	Phone	Relation to Student
Contact 1
Contact 2

Preferred Doctor

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Hospital

Primary Language
What is the primary language used in the home regardless of the language spoken by the student?*
What is the language most often spoken by the student?*
What is the language that the student first acquired?*
What language is preferred for school correspondence?*
Agreement
Do you understand that LEAD Academy does NOT provide transportation to nor from school?*

YesNo
Do you agree to completing 10 hours of Parental Service Hours per year?*

YesNo
Do you understand that if your scholar has 18 or more absences per year that they will lose their seat for the following year?*

YesNo
By signing this form you agree that all of the above statements are true and accurate:*

Clear
Should be Empty: