Performance Academies Enrollment Form - 2020

STUDENT CONTACT INFORMATION

Step 1: You Must Choose a School

Please Choose a School:*

Step 2: Please choose a school year *

2023-2024 School Year 2024-2025 School Year

Students Name (As it appears on Birth Certificate)*

First Name

Middle Name

Last Name

Home Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Enrolling Grade:

** To enroll in kindergarten, students must be five on or before September 30, 2020 **

Date of Birth:*

City of Birth:

Sex (M/F):

Students Ethnicity*

*** Please enter all possible information for mother / father / guardian as it applies.***

Parent or Legal Guardian:*

First Name

Last Name

Relationship:

Address (if different than above):

Address Line 1

Address Line 2

City

State

ZIP Code

Primary Phone:

Description (e.g., "Mother's Cell" or "Home")

2nd Parent Or Legal Guardian: (if applicable)

First Name

Last Name

Relationship:

Address (if different than above):

Address Line 1

Address Line 2

City

State

ZIP Code

Primary Phone:

Description (e.g., "Mother's Cell" or "Home")

Secondary Phone:

Description (e.g., "Father's Cell" or "Work")

Email:

Secondary Email:


	Yes	No
Student is a dependent of a member of the Active Duty Armed Forces?	: Student is a dependent of a member of the Active Duty Armed Forces? (Yes)	Student is a dependent of a member of the Active Duty Armed Forces? (No)
Student is a dependent of a member of the National Guard?	Student is a dependent of a member of the National Guard? (Yes)	Student is a dependent of a member of the National Guard? (No)

Student has access to internet service at home?

Yes No

Student has access to a computer / tablet at home?

Yes No

Is your student currently serving an Expulsion?

Yes No

If yes, please explain

How did you hear about Performance Academies?*

Direct Mail Flyer/Door Hanger Online Billboard Radio TV

Other:

* An unmarried female who gives birth to a child is the sole residential parent and legal custodian of the child until a court of competent jurisdiction issues an order designating another person as the residential parent and legal custodian. A court designating the residential parent and legal custodian of a child described in this section shall treat the mother and father as standing upon an equality when making the designation (See ORC Sec. 3109.042).

STUDENT HISTORY INFORMATION

Enrolling Grade:

** To enroll in kindergarten, students must be five on or before September 30, 2020 **

Previous School Attended:

School Name (Specific )*

Address

City

State

Please list all other children living with the family (Include: Name, Birth Date, Grade, and School Attending):


	Yes	No
Has your student ever received counseling or psychological testing?	: Has your student ever received counseling or psychological testing? (Yes)	Has your student ever received counseling or psychological testing? (No)
Does your student have an active Individualized Education Plan (IEP)?	Does your student have an active Individualized Education Plan (IEP)? (Yes)	Does your student have an active Individualized Education Plan (IEP)? (No)
Has your student experienced any physical, emotional, mental, or social problems within the past two school years? (If yes please explain in the space below)	Has your student experienced any physical, emotional, mental, or social problems within the past two school years? (If yes please explain in the space below) (Yes)	Has your student experienced any physical, emotional, mental, or social problems within the past two school years? (If yes please explain in the space below) (No)


	Suspended	Expelled	No
Has your student ever been:	: Has your student ever been: (Suspended)	Has your student ever been: (Expelled)	Has your student ever been: (No)

If suspended or expelled, please explain:

Please describe any special needs that your student may require including medical conditions, physical limitations, or other special needs of which you would like the school to be aware:

Academic (if any):

Medical / Physical (if any):


	Yes	No
Medications to be given to the student during the school day (if yes, please describe in the space below):	: Medications to be given to the student during the school day (if yes, please describe in the space below): (Yes)	Medications to be given to the student during the school day (if yes, please describe in the space below): (No)

*Note you must also sign a medication permission form*

Items (6) needed to confirm enrollment into the Academy:
Copy of student Birth Certificate
Complete immunization (shot) Records (NOTE: Varicella/Chicken pox vaccine required)
Copy of Individualized Education Plan (IEP), if applicable
Current Proof of Residency (copy of utility bill in the name of the parent/guardian, for example)
Copy of parent or guardian's valid Ohio Driver's License or State ID
Custody/Proof of Guardianship records, if applicable

All of the above referenced items should be submitted to the school as soon as possible.

The School 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 the Boy Scouts and other designated youth groups.

The following person has been designated to handle inquiries regarding non-discrimination policies:

Regional Assistant Superintendent, Two Easton Oval, Ste 525 Columbus, OH 43219, (614) 512-2151

Signature

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