Ivy Academia Re-Enrollment Form for School Year 2017-2018
Please provide the most accurate information.
***FORM MUST BE SUBMITTED NO LATER THAN FEBRUARY 24, 2017***
***IF YOU ARE RE-ENROLLING MORE THAN ONE STUDENT PLEASE SUBMIT ONE FORM PER CHILD***
Email address
1. Student's Last Name
Your answer
2. Student's First Name
Your answer
3. Date of Birth (MM/DD/YYYY)
Your answer
4. Grade Level in 2017-2018
5. Is your son/daughter returning to Ivy Academia for school year 2017-2018?
6. Physical Address
Your answer
7. Mailing Address
Your answer
8. Primary Telephone Number
Your answer
10. MEDIA RELEASE I authorized Ivy Academia the right to artwork, statements, interviews, photographs and audio/visual recordings of my child. This would be for the purpose and/or use, in promotional, educational or fundraising materials including, but not limited to videotapes, pamphlets, websites and brochures. I understand that the last name of the child and/or parent/legal guardian will not be used in connections with said materials. I acknowledge that Ivy Academia shall have all copyrights in and of such photographs and videotapes and may use such copyrights fully. I hereby release Ivy Academia and its administration from all liability connected with the taking and use of said materials. In addition, I waive all rights, interests or claims for payment in connection with any exhibition or release if said materials. I acknowledge that this consent is voluntary and I acknowledge that I have legal authorization to sign this form on behalf of the minor.
Required
11. AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT The undersigned, legal custodian of this students, a minor, hereby authorizes the principal or designee, into whose care the aforementioned minor pupil has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be rendered to said minor upon the advice of any licensed physician and/or dentist. It is understood that this authorization is given in advance of any required diagnosis, treatment, or hospital care and provides authority and power to the aforementioned agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem necessary. This authorization is given provisions of Section 25.8 of the California Civil Code, and shall remain effective for the full school year unless revoked in writing and delivered to said agent(s). I understand that Ivy Academia, its offices and its employees assume no liability of any nature in relation to the transportation of the said minor. I further understand that all costs of paramedic transportation, hospitalization, and any examination, X-ray, or treatment provided in relation to this authorization shall be borne by my undersigned.
12. I verify the the information contained in this document is true and correct to the best of my knowledge. My name is:
Your answer
13. Relationship to child?
14. Today's Date
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
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