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Student Name *
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Address, City, Zip Code *
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Gender *
Student Birthday
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Parent/Guardian #1: Name *
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Parent/Guardian #1: Cell Phone *
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Parent/Guardian #1: Email *
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Parent/Guardian #2: Name *
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Parent/Guardian #2: Cell Phone *
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Parent/Guardian #2: Email *
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Emergency Contact #1: Name, Work Phone, Cell Phone, Email and Relationship to student *
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Emergency Contact #2: Name, Work Phone, Cell Phone, Email and Relationship to student *
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Medical Release Information: Name of Health Insurance Provider *
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Medical Release Information: Primary Physician, Address, Phone *
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Hospital Preference *
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Please list any medical problems, including any required maintenance of medication (i.e. Diabetic, Astma, Seizures). *
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Is your son/daughter presently being treated for an injury or sickness, or taking any form of medication for any reason? *
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Is your son/daughter allergic to any type of food, medication, or material? If yes, please explain. *
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Does your son/daughter have any food restrictions and/or a special diet? If yes, please explain. *
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Medical Release: I understand that I will be notified in the case of a medical emergency involving my son/daughter. In the event that I cannot be reached, I authorize the providing of any/all necessary medical services in the event my son/daughter is injured or becomes ill. Furthermore, I understand that LTS and affiliates will not be responsible for any medical expenses incurred, but that such expenses will be my responsibility as a parent/guardian. Please type your name on the line below that you understand and accept responsibility. *
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Transportation Release: I understand that my son/daughter will be transported to and from various activities via LTS private staff vehicles and/or LTS Bus. In the event of an accident or injury, I agree not to hold LTS financially liable and I also agree to only pursue financial damages from the car insurance coverages/limits available from the specific staff person's vehicle insurance provider and/or LTS bus insurance. I agree not to hold LTS and/or any of it's staff personally liable for financial damages incurred from injuries in the event of an accident while my son/daughter is being transported to and from Life Academy Activities and/or to and from home by LTS staff.
Photo Release: I give permission for my son/daughter to be photographed and/or videotaped during the Life Academy Program. I understand the photographs will be used to keep a visual journal of activities as well as for promotional purposes including printed materials and on the internet. I understand that although my son/daughter's photograph may be used for advertising, his or her identity will not be disclosed. I do not expect to be compensated and understand that all photos are the property of LTS. Please type your name on the line below to indicate that you understand. *
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Code of Conduct Agreement: All students are expected to show respect to the staff, other participants, and the equipment. LTS reserves the right to discuss any situation that may arise, and pending the severity of the circumstances, may also dismiss students for all/part of the Life Academy Program . Please type your name on the line below to indicate that you understand. *
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Dates of the Program: I understand that the Life Academy is a 10 month program from August 12, 2019 - May 29, 2020 and the beginning and ending dates coincide with the Alachua County Schools Calendar. However, the Life Academy has it's own calendar dates with regards to Holidays, which may differ from the School Board Calendar. *
Payment/Attendance Policy: I agree to remit tuition payment(s) to Life Transition Skills, Inc every Monday via check. The weekly tuition cost is $250 - (includes fees for YMCA Membership, Weekly Horseback Riding, & Weekly Bowling and Pizza w/drink lunch combo each Wednesday). This is a 10 month program and weekly tuition must be remitted even if students are absent. I agree to remit full weekly tuition payment(s) of $250. Scholarships are also available based on financial need. Applications can be found here: https://drive.google.com/file/d/0B3UYRtsSs9DbdlpsUFd4S3pRMDE3Smk1SUxXRHF2b1dRdUFV/view?usp=sharing. Please type your name on the line below to indicate that you accept this responsibility. If your son/daughter has been be approved to receive a scholarship, still complete this section, but you may disregard the weekly cost amount listed above. Students receiving a scholarship must remit $10 on Wednesday for bowling and/or $30 if participating in horseback riding on Thursday. *
Part-Time Attendee Policy: Individuals who inform LTS that their son/daughter will only attend part-time for the entire year should adhere to the following: Part-time students must attend at least 2 days in a given week at a rate of $65 per day. If a student is attending on Wednesday, he/she must bring an additional $10 for bowling/lunch. If attending on Thursday and participating in horseback riding, a student must remit an additional $30 fee.
Holiday Policy: The Life Academy WILL NOT MEET on the following holiday dates: Sep 2- (Labor Day) / Oct 4- (UF Homecoming) / Nov 11- (Veterans Day) / Nov 25-29 (Thanksgiving) / Dec 23-Jan 3 (Winter Holidays) / Jan 20- (MLK Day) / May 25- (Memorial Day) - I agree to remit the full tuition of $250 each week even if a holiday occurs during a specific week with the exception of Thanksgiving, Winter Holidays, and Spring Break. During these specified weeks, tuition will not be due. Please type your name on the line below to indicate that you accept this responsibility. *
Inclement Weather Cancellation Policy: Safety is our number one priority with regards to working with your son/daughter. In the unlikely event that our local weather advisory indicates that weather conditions are currently or will become dangerous to the extent that schools are advised to be closed, the Life Academy may also follow-suit in cancelling our program for one or more days. Life Academy administrators will make all final decisions regarding the cancellation of one or more days. In the event that days are cancelled due to poor weather conditions, full weekly tuition of $250 must still be remitted. Please type your name on the line below to indicate that you accept this responsibility to remit the full weekly tuition even if Inclement Weather causes one or more days to be cancelled for the Life Academy. *
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Withdrawal Policy: I agree to provide LTS with a 2-week notice in the event that a student needs to withdraw from the Life Academy Program. After a withdrawal letter is provided to LTS, I agree to remit tuition payment(s) for 2 consecutive Mondays following submission of a withdrawal request. Please type your name on the line below to indicate that you accept this responsibility. *
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I agree to all terms outlined in this document and permit my son/daughter to participate. Please type your name on the line below to indicate that you accept and agree. *
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Thank you very much and we look forward to working with your son/daughter this fall! If you have any further questions, concerns or comments, please feel free to write them below or contact LTS at lifetransitionskillsinc@gmail.com
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