Mansfield Campus Application

Enrollment Mansfield

Name

First Last

Enrolling Grade

The mission of The Legacy Academy of Excellence Mansfield is to provide high quality education that prepares students in grades K-8 for college, career, and life by emphasizing STEAM (Science, Technology, Engineering, Arts/Athletics, Mathematics) in an extended school day environment. Our foremost goal is to engage and advance students academically, prepare them professionally, and expose them culturally.

Items Needed for Enrollment into Legacy Academy of Excellence Mansfield:

Student Proof of Age (birth certificate, I94, etc.)

Complete Immunization Record (Varicella/Chicken Pox required)

Complete Hearing and Vision Report

Copy of Individualized Education Plan, 504, if applicable

Current Proof of Residency (e.g., utility bill, lease, mortgage statement, etc.

Copy of parent/guardian’s valid form of ID (license, state ID, passport, etc.)

Custody/Proof of Guardianship court records, if applicable

All of the above items should be submitted to the school as soon as possible. To enroll in kindergarten, students must be five (5) on or before September 30th. Legacy Academy does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs and activities and provides equal access to programs and activities. The following person has been designated to handle inquiries regarding non-discrimination policies: Dr. Emmanuel Anthony, head administrator at LAE@legacy1870.com. Understand that the Legacy Academy of Excellence Mansfield is a community school established under Chapter 3314 of the Revised Code. The Academy is a public school and students enrolled in and attending the Academy are required to take proficiency tests and other examinations prescribed by law. In addition, there may be other requirements for students at the school that are prescribed by law. Students who have been excused from the compulsory attendance law for the purpose of home education as defined by the Administrative Code shall no longer be excused for that purpose upon their enrollment in a community school. (For more information about this matter contact the Academy administration or the Ohio Department of Education.)

How did you hear about us?

ENROLLMENT APPLICATION

Student Information

Student Name

First Last

Student Date of Birth

City of Birth:

Last grade the student completed:

Proof of Age documentation provided (must be legible): Birth Certificate, Passport, Other

Max. file size: 100 MB.

Student Gender

Parent Information

Parent/Guardian Name

First Last

Relationship to Student:

Parent/Guardian please provide a current, state issued, photo identification. If someone other than mother/father is listed, please provide proof of custody paperwork (date and time stamped by the court)

Max. file size: 100 MB.

Parent Marital Status:

Child Lives with:

Email Address

Parent/Guardian active or former military: Yes or No if yes, please list status

Phone

Work Phone

Parent/Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(Parent/Guardian will be responsible to provide the school with the proof of residency at time of enrollment, any time an enrolled student changes their residency or at the request of the school. Once a student is enrolled parent/guardian must provide the school with proof of residency annually).

Proof of Address provided:

Max. file size: 100 MB.

Deed, mortgage, lease, current homeowners or renters insurance declaration page, utility bill, receipt of utility installation, bank statement, paycheck or pay stub issued to the parent, notification from Social Security and/or Jobs and Family Services, Notarized affirmation from parents of current resident address. (must be current or dated within 30 days of enrollment

Do you need transportation?:(Required)

Please list any siblings who are currently enrolled:

ETHNICITY INFORMATION

Is your child Hispanic or Latino?(Required)

What ethnicity is your child?

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Medical Information:

I agree my child may be physically released only to the following person(s). These person(s) may also be called in the event of an emergency. Proof of identification, in the form of picture ID is required when picking up child(ren). Changes of any release/ contact selections must be received in written form

First Emergency Contact: (Name/Phone Number)

Second Emergency Contact: (Name/Phone Number)

Physician Contact: (Name/Phone Number)

Hospital Preference:

Medical Concern:

Does your child take any medications frequently or daily:

Yes

If yes, what medications are taken daily?

Has your child been diagnosed with allergies by a doctor?

Yes

If yes, please list allergies here:

FOOD ALLERGIES: Does the student have any food allergies?

Yes

If yes, please specify:

AUTHORIZATION TO RELEASE: Who has authorization to pick up the student from school? Please provide the full name of each individual:

1. Name

2. Name

By signing below, I/we agree that my child will abide by and support the Academy rules and regulations, including the Code of Conduct and all other policies. I further confirm that the information provided on this document is true and current. I confirm that I am the legal guardian or custodian of the above student.

Signature

EMERGENCY INFORMATION CARD

Student Name

First Last

Medicaid Number

Address

Social Security Number

Telephone Number

School Attended: Legacy Academy of Excellence

The following is required by section 3313.712 of the Ohio Revised Code. EMERGENCY MEDICAL AUTHORIZATION Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while Under school authority, when parents or guardians cannot be reached. PART I OR PART II MUST BE COMPLETED ALL BLANKS MUST BE COMPLETED

PART I (TO GRANT CONSENT) In the event reasonable attempts to contact me at_______ (A: phone) or _(B: other parent) at (C: phone) have been unsuccessful, I HEREBY GIVE MY CONSENT for (1) the administration of any treatment deemed necessary by (D: preferred physician) Dr.____________ at_(E: phone), or (F: preferred dentist) Dr. _ at_____________(G: phone), or in the event the DESIGNATED preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed.

A: PRIMARY CONTACT NUMBER

B: SECONDARY CONTACT NAME

C: SECONDARY CONTACT NUMBER

D: PHYSICIAN NAME

E: PHYSICIAN'S CONTACT NUMBER

F: PREFERRED DENTIST

G: DENTIST CONTACT NUMBER

FACTS CONCERNING THE CHILD’S MEDICAL HISTORY INCLUDING ALLERGIES, MEDICATIONS BEING TAKEN, AND ANY PHYSICAL IMPAIRMENTS to which a physician should be alerted:

Signature

DO NOT COMPLETE PART II IF YOU COMPLETED PART I

PART II (REFUSAL TO GRANT CONSENT) I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to TAKE NO ACTION OR TO:

PREVIOUS SCHOOL

Please provide information regarding the most recent school(s) the student attended.

SCHOOL #1

SCHOOL NAME:

START DATE

END DATE

REASON FOR LEAVING:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

FAX

SPECIAL SERVICES IEP (MUST COMPLETE)

In order to continue to provide appropriate services, does your child receive Special Education Services at his/her current school?

YES

If you answer YES, a copy of the IEP and ETR must be submitted at the time of enrollment.

Max. file size: 100 MB.

Will the student need 504 services at our school?

YES

Did your student receive English as a Second Language (ESL/LEP) services at his/her previous school?

YES

Does the student lack a fixed, regular, or adequate nighttime residence?

YES

DEFINITIONS:

- Fixed—stationary, permanent, and not subject to change - Regular—used on a regular (i.e. nightly) basis - Adequate—sufficient for meeting both the physical and psychological needs typically met in home environments.

The purpose of this form is to identify and support students who may be eligible to receive services under the McKinney-Vento Homeless Act 42 U.S.C. 11435. The eligibility information on this form is confidential and should be reviewed and re-evaluated every school year. Eligibility is determined on a case-by-case basis. Please contact the school with any questions or concerns regarding the rights of homeless students including immediate enrollment, school selection, transportation, or participation in school programs.

MIGRANT WORKER

Did your family make a move within the past 36 months so that a parent/guardian could work as a migratory agricultural worker, migratory fisher or to join a spouse who is a migratory agricultural worker, migratory fisher?

YES

Do you have a certificate of eligibility for the student from the Ohio Migrant Education Center (OMEC)?

YES

A legible copy of the certificate of eligibility needs to be provided to the enrollment office.

Max. file size: 100 MB.

The school will not exceed the capacity of the School’s programs, classes, grade levels, or facilities. When the number of applicants for admission exceeds the School’s capacity, admissions will be determined by a lottery of applicants. Preference shall be given to students attending the school the previous year, to students who reside in the district in which the school is located, and to siblings of students attending the school the previous year.

REQUEST FOR PERMANENT RECORDS

Name/ DOB (mm/dd/yyyy)

has enrolled in Legacy Academy for Excellence Mansfield IRN

and the students first day is (mm/dd/yyyy)

. District IRN #

TO BE COMPLETED BY PARENT OR GUARDIAN:

Name of school your child last attended:

School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Student Last Grade Attended:

Parent/Guardian Authorization:

Print Name: Parent/Guardian:

Signature of Parent/Guardian:

Date

According to the final regulations of the Family Education Rights and Privacy Act (Buckley Amendments to P.L.93.380) it is no longer necessary to obtain written consent from parents/guardians to release school records. School officials including teachers within the educational institution, and officials in other schools in which the student expects to enroll, may receive a student’s records without consent from parents/guardians for such release.

If a family cannot pick up a student who is refusing to wear a provided uniform, they will be ISS for the day and OSS the following day. Additional instances in which students arrive out of uniform will result in additional consequences and loss of privileges. Please add parent's signature below.

Date

Phone

This field is for validation purposes and should be left unchanged.