Signature of Parent/Legal Guardian: - Saint George …€¦ · Web viewAlso include the page bearing the judge’s signature and court seal. This copy should include any and all modifications

New StudentEnrollment Form

2020-2021*Please provide birth certificate and

immunization record (or exemption form)

Student Information

2020-2021 Grade: _________________ Birthday: ________________________ ☐Male ☐Female

Is the student in their age appropriate grade? ☐Yes ☐No

If no please explain: ___________________________________________________________________

Legal Name on Birth Certificate: ______________________________________________________First Middle Last

Preferred Name: ___________________________________________________________________First Middle Last

Current Physical Address: _____________________________________________________________(No PO BOX) Street Address

_____________________________________________________________ City State Zip

Home Language

What language(s) does the student currently understand or speak? _____________________________________________________________________________

First Language Spoken: _________________________________________________________

Most Used Language: ___________________________________________________________

Home Language: _____________________________________________________________

Home Communication Language: _________________________________________________

STUDENT LIVES WITH: ☐Both Parents ☐Mother Only ☐ Father Only

☐Mother/Stepfather ☐ Father/Stepmother ☐Guardian

Race/Ethnicity

Ethnicity: Is the student Hispanic or Latino? ☐ Yes ☐No

Race: Select all that apply. You must select at least one race below.

☐American Indian or Alaskan Native ☐Asian ☐Black or African American

☐Native Hawaiian or Other Pacific Islander ☐White

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Contact InformationCustodial Parent – First Contact ☐Mother ☐Father ☐Guardian

Parent/Guardian Name: _________________________________________________________________First Middle Last

☐ Mailing Address is the same as aboveCurrent Mailing Address: ________________________________________________________________

Mailing Address

______________________________________________________________ City State Zip

Best Contact Number:☐ Residence☐Cell ___________________________________________________

Alternate Number: ☐ Residence ☐Cell ____________________________________________________

Email Address: ________________________________________________________________________(Please note that all school correspondence is digital)

Work Place: ___________________________________________________________________________

Best Work Number: ____________________________________________________________________

Custodial Parent – Second Contact □Mother □Father □Guardian



Mailing Address

______________________________________________________________ City State Zip




Work Place: ___________________________________________________________________________

Best Work Number: ____________________________________________________________________

Non-Custodial Parent □Mother □Father □Guardian



Mailing Address

______________________________________________________________ City State Zip

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(Non-Custodial Parent Cont.)Best Contact Number:☐ Residence☐Cell ___________________________________________________


Best Contact Number: ☐ Residence ☐Cell __________________________________________________

Alternate Number: ☐ Residence ☐Cell __________________________________________________


Work Place: ___________________________________________________________________________

Best Work Number: ____________________________________________________________________

Emergency Contact □Mother □Father □Guardian



Mailing Address

______________________________________________________________ City State Zip



Work Place: ___________________________________________________________________________

Best Work Number: ____________________________________________________________________

Is there a court decision that the non-resident parent should NOT receive school information or attend school activities? ☐YES ☐NO

***Please attach a certified copy of the court decision establishing a custody or guardianship and include those sections referring to visitation rights and contacts with the school. Also include the page bearing the judge’s signature and court seal. This copy should include any and all modifications made as of the date of registration of the child in this school. It is also the responsibility of the parents to inform the Director of any subsequent modifications during the child’s tenure at the school.

Signature of Parent/Legal Guardian:

Date:

Page 3 of 11

2020-2021 School Directory Option

It is often requested to provide contact information of our students to parents wishing to contact other parents for various reasons. With your written permission (form below) we will include your information in our 2020/21 St. George Academy School Directory. This will be released only to SGA parents. It will not be sold or used for commercial purposes.

Please indicate on the form below your family’s information as you would like it to appear in the 2019/20 SGA Directory. (If you do not want to be included in the directory, do not fill out this form).

(One form per family is preferred, you do not need to fill one out for each student)

Please Print Clearly

We are choosing NOT to have any of our information in the directory. (Do not fill out this form)

YES! Please DO include the following info in the SGA directory.

Student’s name:

Parent’s names:

Address:

Phone: Alt Phone:

Email:


Date:

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Media Release and Consent Form I hereby give St . George Academy, their legal representatives, and assigns, the right and permission to copyright and/or use, publish, and reuse and republish pictures or portraits made of me through any media and for purposes of the marketing and publicizing of St. George Academy. I hereby release, discharge, and agree to save harmless the photographer, St. George Academy, representative, employees, or assigns acting under their direction to distribute the finished product even though the finished product may be blurred, distorted altered or used in composite form, either intentionally or otherwise. I hereby waive any right to approve the finished photography and understand that these images will be used in social media and print forms and I agree to hold blameless St. George Academy for the reactions of others in those forums who may see and comment on said images. I have read the foregoing release, authorizations, agreement, before affixing my signature below and warrant that I understand the contents thereof. For and in behalf of: STUDENT NAME: _____________________________________________________ PARENT/GUARDIAN NAME: ____________________________________________ PARENT SIGNATURE: _________________________________________________ DATE: ________________ Email: ______________________________________________________________

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St. George Academy Annual Acceptance of PolicySt. George Academy asks each family to annually renew their understanding and commitment to the school’s mission, vision, philosophy and policies. Please initial the following statements and sign below to show your acceptance and support.

_____ I have read SGA’s Mission, vision and philosophy. I am committed to support SGA in the fulfillment of these goals.

_____ I understand that SGA has a goal of at least 93% daily average attendance and that parents of SGA are expected to minimize their children’s tardiness and absences. I will make earnest efforts to schedule appointments and lessons outside of school ours and bring my child to school on time. I also understand that if my child has 10 unexcused, consecutive absences, he/she may be unenrolled from SGA.

_____ I understand that all approved policies and procedures are available for review on our website.

_____ I have read, understand and agree to the contents in the Parent Welcome handbook available on our website.

_____ I understand that SGA does not provide transportation and that each family will need to provide their own transportation to and from school.

_____ I understand that SGA does not provide lunch and that each family will need to provide lunch for each of their student every day.

_____ I agree to notify SGA immediately upon any change of information including home address, phone number, email address, health status and family status changes that may affect the child’s living arrangements, safety and/or academics.

_____ If my student is taking prescription medication which must be administered during the school day, I will fill out the appropriate forms in the office. I understand that my child is NOT to keep the medications unless specified by doctor’s instructions.

_____ I understand that SGA’s communication with parents regarding class work as well as school wide events and notices, is digital, and I will be expected to access information from the school via the internet daily.


Date:

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St. George Academy Medical Update 2020-2021

Student Name: _________________________________________________________________________First Middle Last

First Contact ☐Mother ☐Father ☐Guardian


Best Contact Number: ☐ Residence ☐Cell _____________________________________________

Work Place: ___________________________________________________________________________

Best Work Number: ____________________________________________________________________

Second Contact ☐Mother ☐Father ☐Guardian


Best Contact Number: ☐ Residence ☐Cell _____________________________________________

Work Place: ___________________________________________________________________________

Best Work Number: ____________________________________________________________________

Alternate Emergency Contact Emergency Contact Name: _______________________________________________________________________

First Middle Last

Relation to Student: ______________________ Phone: _________________________________

Emergency Contact Name: _______________________________________________________________________ First Middle Last

Relation to Student: ______________________ Phone: _________________________________

Physician Clinic_____________________________________________________ PH________________________

Dentist_____________________________________________________ PH________________________

**In the event of an accident or other emergency, when a parent or guardian is unavailable, I hereby authorize a representative of the school to make arrangements as he/she considers necessary for my child to receive medical/hospital care, including necessary transportation, in accordance with their best judgment. Under such circumstances I further authorize the physician named above to undertake such care and treatment as is considered necessary. In the event said physicians unavailable, I authorize such care and treatment to be performed by a licensed physician or surgeon.**In the event of an accident, the Academy will call an ambulance or the paramedics if staff deems it appropriate. St. George Academy does not carry an accident insurance policy on students. The student’s parents or guardians are responsible for costs incurred as a result of an accident.

**I have read and understand the information included on this form. Furthermore, I accept financial responsibility for all accident/illness- related costs which are not covered by my health and/or accident insurance and I agree to the emergency procedures outlined above and give my consent to have my child receive first aid by school staff.


Date:

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Student Health InformationStudent Name: _______________________________________ PH#___________________________Grade 19/20 _____________ ☐Check here if there are NO known health problems.

VISION AND HEARING☐Known eye condition (other than corrective Lenses).

☐Wears Glasses☐Wears Contacts

☐Worn at all times

☐Known hearing problem ☐Uses hearing aid ☐Has tubes in ears

ALLERGIES☐Food ☐Environmental Comments:

SPECIAL DIETARY RESTRICTIONS:

STUDENT HAS THE FOLLOWING CONDITIONS: Administer during school hours?Condition Medication Prescribe by Doctor Dosage Yes No☐Asthma

☐Autism

☐Epilepsy

☐Fainting Spells

☐Diabetes

☐Heart Condition

☐Migraines

☐Mobility

☐ADD/ADHD

☐Other (Specify)

***(A signed Medication Authorization form, available from the school office, must be on file for any student taking medication, whether physician prescribed over the counter, during school hours. This must be renewed yearly. Per Utah statute, students in possession of prescribed, over the counter, or illegal drugs for personal use, sale, or supplying another student are subject to suspension and/or expulsion.)

Does student have any condition which may result in a classroom emergency?☐Yes ☐NoDoes student have a physical condition which limits participation in:

☐Classroom Activity?☐Physical Education?

Explain:


Page 8 of 11

Date:

Student Discipline History

_____________________________________________________________________________________________Student Name Grade 20/21

Please check the appropriate answer:

1. Does your child have a behavioral intervention plan?………………………………………………………………………….……☐Yes ☐ NoIf “Yes” Please provide SGA with the B.I. Plan.

2. Has your child ever been suspended from school?…………………………….…………………………………………………. ☐Yes ☐No

3. Has your child ever been expelled from school?………………....................................................................☐Yes ☐No

4. Is there any disciplinary action pending concerning your child from his/her previous school of enrollment?............................................................................………☐Yes ☐ No

If you answered yes to any of the above questions, please provide details below.(Include school name Student’s grade level at the time of the incident, approximate date of the incident, describe the incident for which the discipline was taken and the type of discipline handed down by the school).

If your child has a Behavior Intervention Plan, describe any specific behaviors that your child has in response to circumstances.Do you have any specialized way of dealing with that behavior that may also work at school? Please explain:


Date:

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Parent/ Guardian Permission for School Counseling Services

As part of every student’s experience at St. George Academy, the Dean of Students will routinely discuss issues related to academic planning and progress, college/career education and decision making, and personal/social development. Within the private setting of the counseling office, students may wish to discuss personal issues. The Utah Family Educational Rights and Privacy Act (Utah Code 53A-13-301/302) requires that school personnel have your consent prior to discussing these personal issues.

In order to build trust with the student, and maintain a family’s right to privacy, the Dean of Students will keep information confidential with limited exceptions. If a student is deemed a threat to self or others then the parent/guardian will be informed along with appropriate personnel. If information is requested through a court ordered disclosure information may be shared. Information gathered during a counseling session may be shared with the Executive Director. Consultation may be sought with other professionals if additional support is needed. If you would like the Dean of Students to share information with a third party, such as a community counselor, psychiatrist, social services worker, or pediatrician, you will need to sign an additional release of information form.

For further information, questions or concern, please contact the Dean of Student, Ms. Jensen at 435-319-0105.

Please check only ONE of the items below:

☐ I give consent for my student to participate in school counseling services as outlined above immediately and thereby waive the 2-week waiting period. *

☐ I give consent for my student to participate in school counseling services as outlinedabove but would like the services to begin 2 weeks from the below date. *

☐ I do NOT give consent for my student to participate in the school counseling services as outlined above at this time.

I have read and I understand the confidentiality guidelines and exceptions.

Student Signature Date

Parent/Guardian Telephone Number Date

*Utah law requires a 2-week waiting period prior to counseling services being

provided unless parent/guardian agrees otherwise.

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Release of Permanent RecordsSt. George Academy c/o Admissions

380 E 3090 SWashington, UT 84780

[email protected]

1. ______________________________________________________________________________________ Student Name Birthday Grade 20/21

Student one has an IEP ☐YES ☐NO Student one has a 504 ☐YES ☐ NO

Previous School Name: ____________________________________________ Phone: _________________

Previous School Email: __________________________________________________________________

2. ______________________________________________________________________________________ Student Name Birthday Grade 20/21Student two has an IEP ☐ YES ☐ NO Student two has a 504 ☐ YES ☐NO



3. ______________________________________________________________________________________ Student Name Birthday Grade 20/21Student three has an IEP ☐ YES ☐ NO Student three has a 504 ☐YES ☐ NO



You have been identified as the student last school of attendance.

In accordance with UCA 53A-11-504 Requirement of school record for transfer of student – Procedures, and 34 CFR 99-31 governing the permissible disclosure of education records without the written consent of the parent if the disclosure is to officials of another school in which the student seeks or intends to enroll, we request that a certified copy of this students record including the student’s cumulative file, discipline file, U-PASS testing information, the IEP and associated testing as well as 504 Plan be sent to us at your earliest possible convenience.

Thank you for your cooperation on behalf of maintaining the most appropriate educational services for all students.


Date:

Page 11 of 11

Documents

Signature of Parent/Legal Guardian: - Saint George …€¦ · Web viewAlso include the page bearing the judge’s signature and court seal. This copy should include any and all modifications