LIFLl

E LIFE Academy: Enrollment Form

Legal Name of Student: ______________________________________________________ Grade Entering: Last First M.I.

Preferred Name: Gender: El Male 0 Female Birth date: ---J I Month Day Year

Home Address: Street

City State Zip

Mailing Address (if different):

Home Phone: ()

ACADEMICHISTORY

Previous School: -- - Name of School Address City State Zip Phone Number

Date Last Attended:__________________

ADULT WITH WHOMSTUDENT LIVES

Parent/Guardian: Relationship to Student:___________________

Place of Employment: Work#: Cell#:___________________

Parent/Guardian:__________________________________________________ Relationship to Student:___________________

Place of Employment: Work#: Cell#:___________________

Sibling(s) 1 2 3

EMERGENCY INFORMATION

Name of Emergency Contact:_____________________________________ Relationship to Student:__________________

Phone#: Work#: Cell#:___________________

Doctor’s Name: Phone#: Insurance Carrier:_________________

HOMELANGUAGE

What is the primary language used in the home regardless of the language spoken by the student?__________________

ETHNICITY (select your DOMINANT ethnicity Lp!ease check ONLY Q) r-1 White/Not Hispanic LI Black/African American U Hispanic El Asian/Pacific Islander American Indian/Alaskan Native

Birthplace City, State, Country:

I hereby affirm that all information provided is correct. I understand it is my responsibility to keep this form updated NOTE; The 5o’loal will not honor requests of restrictions unless cop/es of custody papers or court orders that support the request are on file.

Parent/Guardian Signature____________________________________________ Date:

Email Add

TTT LWi

LIFE Academy: Emergency Information and Immunization Record Card

Child’s Name: Date Enrolled: Updated:

Home Address: Street

City

State Zip

Home Phone:

Date of Birth: - Sex: male D female [J

Mother or Guardian

Name:

Home Address:

Street City State Zip

Home Phone: Phone:_________________

Business Name:_ Work Phone:______________

Business Address:___________________________________________

Street City State Zip

Signature:

If Medical Care is Necessary, Call:

Father or Guardian

Name:

Home Address:__________________________________________

Street City State Zip

Home Phone: Phone:__________________

Business Name: Phorje:_____________

Business Address:___________________________________________

Street City State Zip

Signature:_

DOCTOR: Name Address City State Zip Phone

HOSPITAL: Name Address City State Zip Phone

Does your child have insurance coverage? No Yes Name of Insurance Company (Optional)

In case of injury or sudden illness, will be called first. I herby give authority to any hospital or doctor to render immediate aid as might be required at the time for his/her health and safety. It is understood by me that the expense of this service will be accepted by me.

In case of emergency, or if I cannot be contacted to pick up my child, I herby authorize the following person (s) to pick up my child:

Name: Name:___________________________________________________

Address: Address: Street City State Zip Street City State Zip

Home#: Cell #-. Cell #:________

The foflowina person(s) may not remove my child from the center:

Name: Name:

Custody papers have been provided and are on file at the facility. Yes No

This Emergency Information and Immunization Record Card is accurate and complete. front and back, and was provided by:

Parent or Guardian printed name Signature Date

0 Academy Emergency & Transportation Information

Please be advised that (client being served) has my

permission to be transported by Lauren’s Institute for Education providers and may ride on public

transportation (e.g. school buses), as Lauren’s Institute for Education may deem necessary and

appropriate.

Further, in case of an emergency and I cannot be contacted, Lauren’s Institute for Education providers

have my permission to see to emergency care on behalf of the below named.

Parent signature of agreement:

Child ’s name:

DOB:

Home address:

Parent home #:

Parent cell #:

Parent work #:

Email:

Name of emergency contact:

Relationship to student:

Phone #:

Name of emergency contact:

Relationship to student:

Phone #:

Date:

Insurance & ID number:

Primary care physician:

Is your child taking any medications at this time?

Yes/No If yes, please list:

Is your child on a special diet?

Yes / No If yes, please list:

Does your child have any food allergies?

Yes / No If yes, please list:

Does your child have any known drug/miscellaneous

allergies?

Yes / No If yes, please clarify:

LIFE Academy: Temporary Acceptance 30 Day Notice

Student’s Name

Dear Parent or Guardian:

The 1987 legislature passed a law designed to help trace the location of any child who is reported missing. So that the schools may assist you in this effort, A.R.S. 15-828 requires that you, the parent or guardian of the child you are enrolling in our Academy, provide one of the following to this office within 30 days of registration:

This information must be provided not later than

� A certified copy of the child’s birth certificate.

Other reliable proof of the student’s baptismal certificate, an application for a Social Security number, or original school registrations records ad a signed affidavit explaining the inability to provide a copy of the birth certificate.

A letter from the authorized representative of an agency having custody of the student (pursuant to A.R.S. 15-828) certifying that the student has been placed in the custody of the agency as prescribed by the law.

If you need to obtain a certified copy of an AZ birth certificate, you can contact the Arizona Department of Health Services Office of Vital Records at 602-364- 1300 or online at www.adhs.gov . If you need to obtain a copy of a birth certificate from another state, you must contact that state’s office of vital records.

On the failure of a person enrolling a pupil to comply within 30 days, the school, school Academy or county school superintendent shall notify that person in writing that, unless the person complies within ten days, the case shall be referred to the local law enforcement agency for investigation,

Please sign below to indicate receipt of this letter.

Signature

Date

F E 2 LIFE Academy: Authorization and Request for Release of Student Records

I hereby authorize the release of records for the following student:

Student’s Name

Date of Birth

Grade

Name of Previous School

Address of Previous School_______________________________________________________________

Phone #

Fax#

Official Transcript of Grades - Please mail Withdrawal Grades with Withdrawal Form

Test Scores: Stanford 9, AIMS, SAT, PSAT, Tera Nova, ACT & etc. Attendance Records

Birth Certificate Medical Records

Discipline Records

Special Education Records IEP

Psych. Evaluations

Please mail or fax to: Laurens Institute for Education 3271 E Queen Creek Rd, Ste. 101 Gilbert, AZ 85297 (480) 621-8361 Fax: 480-621-8513

Signature of Parent/Guardian or Registrar Date

THE FAMILY EDUCATION RIGHTS AND PRIVACY ACT (FERPA) STA TES:99. 31 Under what conditions is prior consent not required to disclose information? (a) An educational agency or institute may disclose personally identifiable information from an education record of a student without the consent required by 99.30 if the disclosure meets one or more of the following conditions; (1) The disclosure is to other school officials, including

teachers, within the agency or institution whom the agency or institute has determined to have legitimate education interest. (2) The disclosure is, subject to the requirements of 99.34, to officials of another school, school system, or institute of postsecondary education where the student seeks or intends to enroll.

Request For Exemption To Immunization Child Care Centers

If you wish for your child to be exempt from the immunization requirements, this form must be completed, signed and returned to the child care center. As stated in Arizona Administrative Code R9-5-305, your child will not be allowed to attend child care until either a record of immunization or this exemption statement is submitted. Please indicate below the type of exemption requested and complete all required information. In the event of an outbreak of a vaccine preventable disease for which you can not provide proof of immunity of your child, your child will not be allowed to attend child care until the risk period ends.

Medical Reasons - If the immunization would be a health risk to the child because of pre-existing medical conditions, you must sign the statement below along with your physician’s signature. Your physician must state the reason for the medical exemption. The exemption may be for one or more vaccines, and may be either permanent or temporary. If the condition is temporary, the date of its end must be given, at which time the child must receive any necessary vaccine doses.

Religious Beliefs - If immunizations are against your religious beliefs, you must sign below to exempt your child from the requirements.

Laboratory Evidence If your child has previously had a vaccine preventable disease, immunization against that disease is not required if laboratory evidence of immunity signed by a physician can be provided. Copies of lab results must accompany this request.

Complete And Return This Form To Your Child’s Child Care Center:

I hereby request an exemption from the immunization requirements for the child listed below, have received information about immunization and understand the risks and possible outcomes of this decision.

Child’s Name

Type of exemption requested (Mark one) - Medica l* (See below)

Religious Beliefs Laboratory Evidence

Date of Bi (month, day, year)

For the following vaccines: (Mark all that apply)

Diphtheria Tetanus Pertussis Vancella Measles Mumps Rubella Polio Hepatitis B Hepatitis A

- Haemophilus influenzae type b

* If a medical exemption is marked, complete the following:

Reason for medical exemption: Length of exemption:

Permanent Temporary until:

Required Signatures: Parent or guardian must sign all requests and physician must also sign any requests for medical or laboratory evidence exemptions:

Prnt or flt rrin

Pfn,cirior,

Printed Name

Printed Name

Date: month, day, year

Date: month, day, year

C:Ducurnents and Setti sthenkemiHS\My Oocuments\My WebsLS\dnldcare\orig\Request for Child Care Immunization Exernption.doc ADHS 209C Child Cars Exemption Form Rev 4108

Soilcitud De Exencion De Inmuniacion En Guarderias

Si Ud. quiere que a su hijo se le exente de los requisitos de irimunizaciOn, es necesarlo rellenar, firmar, y devolver a la guarderla esta soilcitud. Segün reglamento estatal R9-5-305 a su hijo no se le permitirÆ asisitir a la guarderia sin haber presentado su libro de vacunas o esta solicitud de exención. Favor de indicar abajo la clase de exención que Ud. pide y rellene la información necesaria. En el caso de un brote de una enfermedad que se podria prevenir con vacuna, si Ud. no puede presentar prueba de inmunidad para su hijo no se le permitirÆ asistir a la guarderla hasta que pase el perlodo de riesgo.

Motivos Medicos - Si vacunarse serla un riesgo a la salud de su hijo a causal de un problema medico ya existente, ambos Ud. y el medico deben firmar Ia declaración que se encuentra abajo. Se puede declarar exenciOn de ur,a o mÆs vacunas y cada exenciOn puede ser ó temporal ô permanente. El medico tiene que afirmar el motivo de la exención. Se puede exentar de una o mÆs vacunas y cada exención puede ser ó temporal ó permanerite. Si el problema medico es temporal, se debe indicar la fecha esperacla de su final. Es a partir de esta fecha que serÆ obligatorlo vacunarle a su hijo.

Creencias Reliqiosas - Si vacunarse va en contra de creencias religiosas que tiene Ud., hay que firmar la declaraciôn abajo para exentar a su hijo de las vacunas requeridas.

Prueba De Laboratorlo - Si su hijo ya ha sufrido de una de las entermedades contra las que se suele vacunar, no es necesarlo que se le vacune contra esa enfermedad siempre que Ud. pueda presentar prueba de inmunidad que procede de un laboratorio, firmada por el medico. Copias de los resultados del faboratorio tienen que acompanar esta solicitud.

Favor De Rellenar Y Devolver Esta Solicitud A La Guarderia De Su Hio:

SoUcito una exención de los requisitos de inmunización para el niæo indicado abajo. He recibido información sobre as vacunas y entiendo los posibles riesgos y consecuencias de esta decision.

Nombre del niæo Fecha de nacimiento (mes, dia, aæo)

La clase de exenciôn que se pide: Para las vacunas siguientes: (Marque uno) (Marque todas que corresponden)

- Motivo mØdico* (Vease abajo) Difteria TØtarto los ferina Varicela - Creencias religiosas Sarampión Paperas RubØola - Prueba de Iaboratorio Polio Hepatitis B Hepatitis A

Haemophilus lnfluenzae tipo B

* Si Ud declara exenciOn por motvo medico, rellene lo siguiente:

Motivo de la exención: DuraciOn de la exenciOn

Permanente Temporal hasta

Firinas necesarias: Se requiere que un padre, madre, o tutor firme esta solicitud. TarnbiØn es necesaria la firma del medico.

Padre, madre, o tutor Medico

Nombre escrito en letras de imprenta Nombre escrito en letras de imprenta

Fecha: mes, dfa, aæo

Fecha: mes, dia, aæo

Este Documento es una traducción tomada del texto original escnto en ingles. Esta traduccidn no Cs oficial y no esta vrnculado a este Estado o a ninguna subdivisiOn polItica de este Estado. This document is a translation from original text written in English. This translation is unofficial and is not binding on this state or a political subdivision of this state.

ADHS 209C Chid Care Exemption Form Rev 4108

0 g!LICE L.I.F.E. Academy

Assessment and Evaluation Process

When will my child’s assessments take place?

During the month of July, current students will be assessed on Tuesdays. An assessment appointment

time will be coordinated with each family. Assessments should last no longer than 1 hour.

Students enrolling during the school year will have a complete assessment done prior to placement

When will I see the results of my child’s assessments?

During the week prior to the first day of the new school year, a L.I.F.E. Team Meeting will be held to

discuss the results of the assessments in the form of an Individualized Learning Plan (ILP). At this time,

teachers will meet with the parents to discuss each child’s ILP and explicitly explain the child’s current

assessment results, goals for the school year, and how these goals will be reached.

Students enrolling during the school year will have a L.I.F.E. Team Meeting once the assessment process

has been completed to discuss the same as mentioned above.

What is an lIP? Is it like an IEP?

lEPs are only required for students enrolled in a public school environment. There is no current

obligation for private or non-profit schools to develop IEPs for its students. However, at L.I.F.E. Academy,

we want our parents to receive as much information regarding their child’s progress as possible.

Therefore, we will be utilizing our own version of an IEP that we are calling an Individual Learning Plan

(ILP). This document will outline your child’s current assessment results, specific goals for each quarter

of the school year, and a description of strategies used to achieve these goals.

Will there be opportunities throughout the year to communicate about my child’s

progress?

In October and February of the current school year, Academy Teachers will hold parent-teacher

conferences to update parents on their child’s progress. Topics of these conferences will include their

child’s quarterly goals and current progress in the classroom environment.

What assessments will be used with my child? Depending on your child’s skill sets, we will be using any combination of the following assessments to

determine the most appropriate goals for each student.

� Reading Mastery (Phonetic reading and language arts skills)

� Saxon (Kindergarten - 3rd grade math skills)

� Edmark (Sight-based reading program)

� Skill Assessment

Private schools are not obligated in any way to provide assessments or to develop IEP’s. Under the Child

Find requirements of the Individuals with Disabilities Education Act (IDEA), public school districts are

required to provide assessments for students who attend private schools located within the boundaries

of the district. The student’s parent must make a request for such an assessment and make the student

available to the school district. Once the assessment is complete, the team, including the parent, makes

a determination of eligibility for special education services. If the student is eligible, the parent can then

decide whether or not to enroll the student in a public school. Upon enrollment, the public school would

convene an IEP team, again including the parents, to determine what services would be necessary and

how and when those services would be delivered. IEPs are only required for students enrolled in a public

school, if the student does not enroll, there is no individual entitlement to services.

There is, however, a requirement for districts to set aside a portion of their IDEA grant dollars to provide

services to students attending not-for-profit private schools located within their boundaries. How these

funds will be spent is decided at the beginning of each school year through consultation with private

school administrators and representatives of home-school students. The funds may be earmarked for a

specific type of service, such as speech therapy, and only those students requiring that service are

included. In addition, the funds are finite, so when the dollars are gone, the service ends. IF there are

students who are eligible for special education and require the service identified, an Individual Service

Plan (ISP) is developed. Please note that this plan does not carry the same legal protections as an IEP.

Here are additional support contacts for your assistance:

The Arizona Center for Disability Law provides workshops for people with disabilities, their families and

professionals. Training include understand IDEA, developing an IEP, advocating for special education,

guardianship, etc. Training schedule can be viewed on website, along with workshops sponsored by

several other agencies.

Their website: http://www.azdisabilitylaw.org/training.html

And the phone 602-274-6287

Arizona Department of Education - Parent Information Network They provide fee training in the

Special Education Process, IEP (Individualized Education Program), self-advocacy and disability

awareness. Also provides special education and disability specific resources from the clearinghouse,

assistance with developing parent advisory councils and parent support groups. Offers consultations to

staff regarding building parent/professional collaboration and consultations to parents to help them

actively participate in their child’s special education.

http://www.azed.gov/ess/das/pinspals

877-230-7467 or 877-230-PINS

Community Information & Referral You can call 602-263-8856 or 800-352-3792 to find resources for

all of Arizona. The helpline is available every day, 27-hours, including holidays. They also publish an

annual Directory of Community Resources and maintain an online database at

www.cir.org/firstcall-serach.html.

L.I.F.E. Academy Tuition: $26,000.00

Funding Options:

Empowerment Scholarship Account In order to qualify for the Empowerment Scholarship Account program the applying student must be identified by a school district as a child with a disability as defined in section 15-761 under the Arizona Revised Statutes, or who is eligible to receive services from a school district under A.R.S. § 15-763. Students without a verifiable disability do not qualify for an ESA. A student must have attended a public school for 100 days prior, hold a current LEP/MET and or have received a qualifying grant from a STO.

Please begin by visiting; www.azed.gov/esa

Lexi’s Law Monies: A child must have attended a public school for 100 days prior to enrolling in our private academy. Every Child must first meet eligibility through the Department of Revenue, Karen Jacobs. Every Child must complete a Lexi’s Law Application through TOPS each and every year if they have been approved by Karen Jacobs at the Department of Revenue. The maximum a child can receive is based on what the Public School System would have received, this is based upon their eligibility and needs, this can range from $3,000 to $20,000.00.

Please begin by visiting: www.topsforkids.com

Corporate Tax Credit Monies: In order for a child to receive funds through the Arizona Corporate Tax Credit fund, they must meet the financial requirements of the Federal Reduced-Lunch Program Guidelines. If your families meet the requirements you must complete a Corporate Tax Credit Application through TOPS. The maximum a family who qualifies can receive is $4,800.00.

Please begin by visiting: www.topsforkids.com

Individual Tax Credit Monies: If you are married and filing jointly you are allowed to contribute

up to $1,000, and if you are single/head of household your allowable contribution is $500. A

friend and or family member may designate your child specifically and or L.1.F.E. Academy. A

parent of a child who contributes through this program may not designate their funds to their

child but rather should designate L.I.F.E. Academy. Every family needs to complete the

Individual Tax Credit Application through TOPS. The maximum a child can receive is

$26,000.00 and or up to $26,000.00.

Please begin by visiting: www.topsforkids.com

We ask that each and every L.I.F.E. Academy family make a commitment to raise $2,000.00 in Individual Tax Credit Monies to be designated to Lauren’s Institute For Education regardless of their child’s own personal funding. We ask that half be committed by December 31St and the other half by April 15 th �

Donation: For Friends and Families that do not live in the great State of Arizona but wish to support our center, they may do so through a regular charitable donation. They would send their payment to Lauren’s

Institute For Education, 3341 East Queen Creek Road, #109, Gilbert AZ 85297. They will receive a donation acknowledgement directly from our finance department. For families that work for a company that has a Matching Contribution Program, the giving corporation will receive a donation acknowledgement letter directly from our Finance department.

IMPORTANT: A Parent, Friend and or Family member cannot designate their donation to a specific child, this constitutes a FEE FOR SERVICE and does not qualify as a donation.

Parent Payment Plan:

For Children with minimal outside funding;

If your child receives funding through one or more of the above programs yet still falls under the

minimum requirement of $6,000.00 per academic year, you will be contacted to set up monthly

payments in order to meet the minimum requirement. The Individual Tax Credit donation commitment

of $2,000.00 will be deducted from this balance upon verification through a TOPS receipt. For Example;

you receive a 3,500.00 scholarship through TOPS or through ESA, you make your $2,000.00 commitment

through TOPS pledged to Lauren’s Institute For Education, you are able to provide a receipt confirming

the donation, you would then only be required to make monthly payments up to and no more than

$500.00 for a grand total of $6,000.00. Total amount of tuition is due by May 1st of the academic year.

We are notified in July before the Academy year begins of everyone’s funding, once we receive your

child’s scholarship award we will contact you to make the appropriate arrangements.

For Children without funding ootions:

For the families who have children who do not meet the eligibility requirements for the above funding

options and you wish to enroll your child in our Private Academy you may do so under a cash payment

policy.

Regardless if a child receives outside funding and or not, there is a $6,000.00 minimum requirement for

each and every child who attends the L.I.F.E. Academy. At the time of enrollment you will be set up on a

monthly payment plan which consists of $400.00 a month for 10 months. This totals $4,000.00. In

addition to your monthly payment you will also be expected to meet your commitment of raising

$2000.00 in Individual Tax Credit Donations due in part December 31’t and the other part due by April

15th The total amount of tuition is due by May 15t of the academic year. If you do not feel you will be

able to raise $2,000.00 through friends and family and would rather us set up your monthly payments to

cover the entire $6,000.00 at the beginning of the Academy year, you will just need to let our finance

department know.

I have read the above tuition options and understand my personal commitment will be based upon my

child’s funding options and or lack thereof. I understand if I proceed with enrolling my child in the

L.I.F.E. Academy I am agreeing to meet my child’s tuition requirements as stated above.(return copy)

Parent

Signature: Date

Dear Parents;

In an attempt to help you navigate your funding options as best as we can, we have created this

document for you to follow. Should you have any questions however please do not hesitate to contact

Carrie Reed and or Myself directly, carrie@laurensinstitute.org and or margaret@laurensinstitute.org

In order to qualify for these funding sources your child must have a current IEP and or MET, must have

attended a public school for 100 days prior and have a disability as defined in section A.R.S. 15-763.

There are 3 primary websites you must visit and complete the appropriate documents before entering

our academy;

1. State of Arizona Department of Revenue-Scholarships for Disabled/Displaced Students

provided by School Tuition Organizations - Application for Eligibility (This must be completed

before you can begin the application process through www.topsforkids.com

There are 3 documents you will need to print and or complete from this website;

a. Instructions For Application for Eligibility for Disabled/Displaced Students

b. Application for Eligibility for Disabled/Displaced Students

c. Public School Enrollment Verification

http://www.azdor.gov/TaxCred its/CorporateluitionTaxCredits/Disa bled DisIacedSchoIa rships.a

SPX

2. The Arizona Department of Education Empowerment Scholarship Account

There are 4 documents you will need to print and or complete from this website;

a. Empowerment Scholarship Account (ESA) Fund Use

b. Official Notice of Pupil Withdrawal

c. Empowerment Scholarship Account School Verification Form

d. Empowerment Scholarship Account Application Eligibility Determination

http://www.azed.gov/esa

3. TOPS for Kids and Arizona School Choice Trust

There are 3 separate scholarship applications you will need to complete online from this website

(These applications must be renewed and or completed before each school year begins);

a. Individual Scholarship Application

b. Corporate Scholarship Application

c. Lexie’s Law Scholarship Application

d. Plus "switcher" Application

www.topsforkids.com and http://www.asct.org

*I n addition to these sites, here is an additional grant/scholarship site you may be interested in

reviewing. http://www.uhccf.org/apply.html and 2. http://www.asct.org/index.asp