Enrollment Application
Relevant Academy of Eaton Country

512 East Lovett Street, Charlotte, MI 48813.
Office: (517) 541-8949. Fax: (517) 541-3141

Email us at: info@relevantacademy.org
Visit our website: www.relevantacademy.org

Learner Information
Last Name *
Learner Last Name
Your answer
First Name *
Learner First Name
Your answer
Middle Name
Your answer
Learner Date of Birth *
MM
/
DD
/
YYYY
Learner Gender *
Learner Place of Birth *
city, state
Your answer
Learner Address Line 1 *
house number & street name
Your answer
Address Line 2
apartment/condo /P.O. Box number if applicable
Your answer
City *
Your answer
State, Zipcode *
Your answer
County of Residence *
Your answer
Learner Phone Number *
(___) ___-___
Your answer
Learner Email
Your answer
IEP/504 Status
Rule 340.1721b (5) of the Michigan Administrative Rules for Special Education requires that, for students with an individualized education program in effect at a previous pubic agency who transfer public agencies within the same school year, the new public agency shall immediately provide a free and appropriate public education. A decision regarding implementation of an individualized education program in accordance with 34 CFR § 300.323 shall be made within 30 school days of enrollment.
Do you Currently Have an active IEP? *
Do you Currently Have an active 504? *
Learner Idenity
Is this learner Hispanic/Latino? *
Please select one
What is the learner's race *
Choose all that apply
Required
Multiple Birth? *
ex: twin, triplet
Parent/Guardian Information
Please fill out required information for at least one parent/guardian.
Parent/Guardian 1 Name *
First, MI, Last
Your answer
Parent/Guardian 1 Address Line 1 *
House number & Street name
Your answer
Parent/Guardian 1 Address Line 2
Apartment/Condo/P.O. Box Number if applicable
Your answer
City *
Your answer
State, Zipcode *
Your answer
Parent/Guardian 1 main phone number *
(___) ___- _____
Your answer
Parent/Guardian 1 additional phone number
(___) ___-_____
Your answer
Parent/Guardian 1 Email
Your answer
Parent/Guardian 2 Name
First Name, MI, Last Name
Your answer
Parent/Guardian 2 Address
street address, state, zipcode
Your answer
Parent/Guardian 2 main phone number
(___) ___- _____
Your answer
Parent/Guardian 2 additional phone number
(___) ___-_____
Your answer
Parent/Guardian 2 Email
Your answer
Emergency Contact Information
Emergency Contact Name
First Name, MI, Last Name
Your answer
Emergency Contact Address
street address, state, zipcode
Your answer
Emergency Contact phone number
(___) ___- _____
Your answer
Emergency Contact Email
Your answer
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