ENROLLMENT PACKET
Complete all forms and return to: MADISON ACADEMY
Elementary Campus 6170 Torrey Rd. Flint, MI 48507 Office: (810) 655-2949
High School Campus 3266 S. Genesee Rd. Burton, MI 48519 Office: (810) 875-9050 Current or prospective students not returning completed forms may forfeit their place for 2015-16
Dear Parent or Guardian: Welcome to Madison Academy. I’m pleased to inform you that your child’s application is being considered for enrollment. We are excited about the educational opportunities we will be able to offer the students in our community. To officially enroll your child in Madison Academy for the 2015-2016 school year, a student must be entering any grade from Pre-Kindergarten – 12th and complete the following steps: 1 Submit a complete enrollment form for each child attending Madison Academy. (See attached form) 2 Include with the application: ■ A copy of the applicant’s birth certificate ■ A copy of the applicant’s most recent report card (grades 1-12) ■ A full transcript (grades 7-12) ■ A copy of the applicant’s complete immunization record. ■ Please Note: If you object to having your child immunized, a waiver must be completed at the Genesee County Health Department. Please call (810) 257-3612, for additional information or to schedule an appointment. ■ A complete health report, signed by the appropriate medical personnel, must be turned in as soon as possible. ■ A copy of the applicant’s behavior records for the past 5 years. ■ A copy of the applicant’s most recent IEP (special education only) Special Note: Enrollment will be considered incomplete unless ALL indicated items are completed and returned. The above-completed forms may be mailed or returned to:
Elementary Campus High School Campus Madison Academy Madison Academy 6170 Torrey Rd 3266 S. Genesee Rd Flint, MI 48507 Burton, MI 48519 If you have any questions, please feel free to call the school at: 810-655-2949 (Elementary) or 810-875-9050 (High School). Sincerely, Tricia Osborne Joddi A. Mills Principal, Pre-K-8 Principal, High School
Enrollment Form Please print or type all information 2015-2016 School year
Enrollment Information: Grade in 2015-2016 ____________ Student Name (as it appears on birth certificate): Last_______________________First:_______________________ Middle: _______________ Name your child goes by: ___________________________________ Gender: Male / Female School District in which student lives: _____________________________________________ Address: _________________________City: ________________ State: _____ Zip: ______ Home Phone Number: _________________________________ Date of Birth: _______________Place of Birth: ____________________Age: _____________ (As it appears on birth certificate) Ethnicity: African American / Asian / Caucasian / Hispanic / Native American / Other _ Primary language spoken in the home______________________________
Previous School Attended _______________________________________________________ Highest Grade Completed ______________ Does your child have an IEP? Yes _____ No____ Is your child in a special education program? Yes_____ No_____
Parent/Legal Guardian Information: Parent/Legal Guardian Name (1): ____________________________Relationship: _________ Address: _______________________ City: ___________________State: ______ Zip: ______ Home Phone Number: _______________________ Work Phone Number: _______________ Cell Phone Number: _________________________ Alt. Number: ______________________ Email Address:_______________________________(Optional) Work Place: ____________________________________ Hours of Employment: __________ Parent/Legal Guardian Name (2): ____________________________Relationship: _________ Address: _______________________ City: __________________State: ______ Zip: ______ Home Phone Number: _______________________ Work Phone Number: _______________ Cell Phone Number: _________________________ Alt. Number: ______________________ Email Address:_______________________________(Optional) Work Place: ____________________________________ Hours of Employment: __________ Student resides with: Both Parents____Mother____Father_____Guardian____Other ___________ Mothers highest level of education: Did not complete high school____High School diploma or equivalent____ some college____2yr. degree____4yr. degree_____other___________Military_________ Fathers highest level of education: Did not complete high school____High school diploma or equivalent____ some college____2yr. degree____4yr. degree_____other___________Military_________
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Sibling Information:
Names of other children living at home
Age Relationship to student
Grade Applying for 2015-16
Grade in 2014-15
Previous School Information: The last school student attended was: ___Non-Public in district ___Public in County ___Non-Public in State ___Public in State ___Out of State ___Out of USA ___No Previous School Why are you leaving your current school? ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ _______________ ________________________________________________ ____________________________ Parent/Guardian Signature Date How did you hear about Madison Academy? ___Newspaper ____ Church ___Radio ____ Other (Please Specify) ___Friends _______________________________ ___Relatives
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REQUIRED EDUCATION INFORMATION
Student Name _______________________________________________________________________ Last First Middle Date of Birth ___________________ Age___________________ Grade ______________
Previous School attended? ________________________________________
Is your child currently under suspension? Yes_____ No______ From what school? ___________________________________
Date(s) _____________________________________________________________________________
Reason(s) ___________________________________________________________________________
Has your child been expelled? ________________
What school? ___________________________________
Date(s) _____________________________________________________________________________
Reason(s) ___________________________________________________________________________
Has your child been retained? _____________________Grade(s)______________________________
What school? _____________________________
____________________________________________________________________________________ Signature of Parent/Legal Guardian Date
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SPECIAL EDUCATION INFORMATION
Student Name _______________________________________________________________________ Last First Middle Date of Birth ___________________ Age___________________ Grade ______________
Does your child have a current IEP ? _______________
Does your child have a current 504 Plan? ________________
Previous School attended? ________________________________________
Has your child been expelled? ________________
What school? ___________________________________
Date(s) _____________________________________________________________________________
Reason(s) ___________________________________________________________________________
Has your child been retained? _____________________Grade(s)______________________________
What school? _____________________________
____________________________________________________________________________________ Signature of Parent/Legal Guardian Date
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MEDICAL CONDITION(S)
Student Name: ___________________________________________________________
_____ YES, My child has a medical condition / and or allergies.
_____NO, My child does not have a medical condition / and or allergies.
List Medical Condition / and or allergies in detail: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
● Please attach any relative information regarding the medical condition.
MEDICAL RELEASE
I,___________________________________________, do not hold Madison Academy (Parent’s name) responsible for unintentionally forgetting to administer medication to my child,
___________________________________________. (child’s name)
I understand that staff members can forget and I take this risk by asking
___________________________________________ to give the medication. (Office staff member name)
If I want to ensure that my child receives the medication, I have the right to come into the school and administer this medication to my child.
______________________________ _____________________ Parent Signature Date
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AUTHORIZATION FOR RELEASE OF STUDENT RECORDS
Date: _____________________________
Student’s Name ________________________________________Age: ____________
Date of Birth: ____________________ Highest Grade completed: _____________
School Releasing Information: _________________________________________ Name of School _________________________________________ Street Address _________________________________________ City, State, Zip Code _________________________________________ Records Requested: Phone # ___Standard Education Report ___Immunization Record ___VHD certificate ___Psychological Report ___Spec. Ed & IEP ___Gifted Eligibility ___ESOL & ESL Record ___Disciplinary Report ___Other ________________
Is the student currently under suspension____Yes ____No If Yes, for how long?____________________________ For what reason? ______________________________ This release also confirms that this student has not been expelled by a former school due to a “Weapons in schools” infraction or “physical or verbal assault” infraction.
_________________________________________________________ Signature of Parent/Guardian confirming release information and no “Weapons in Schools” or “physical or verbal assault” infraction.
_____________________________________________________________________________ Signature of Former School Administrator confirming above
Please send information to: Madison Academy Elementary Madison Academy High School 6170 Torrey Rd. 3266 S. Genesee Rd. Flint, MI 48507 Burton, MI 48519 Fax # 810-655-2931 Fax # 810-877-6255