Student Name: Date: Entering Grade (2016-2017): Circle One 9 10 11 12 Required Forms




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Mentorship Academy Student Enrollment Form 2016-2017

Student Name: Date:
Entering Grade (2016-2017): Circle One 9 10 11 12
Required Forms:
Two (2) Proofs of Address
Immunization Record
Mentorship
Academy

2016-2017


Enrollment Packet


group 367 Social Security Card
group 362 Birth Certificate


IEP/504 Documentation (if applicable)

9th grade:
8th grade final report card

8th grade LEAP/PARCC scores
10th grade:
High school transcript indicating credits received

group 358End of Course exam (EOC) test scores
11th grade:
group 356High school transcript indicating credits received

group 354End of Course exam (EOC) test scores
12th grade:
High school transcript indicating credits

group 349 End of Course (EOC) exam test scores
Mentorship
Academy, the high school of the future, welcomes your scholar to a rigorous education with a focus in science, technology, engineering, arts,

and Mathematics.



339 Florida Street Baton Rouge, LA • 70801


Office 225.346.5180 Fax 225.636.2003
www.mentorshipacademy.org




MA Student Intent-to-Attend Form 2016-2017
Mentorship Academy is making great strides in improving the academic achievement levels of our students, and hopes that you will make a commitment to partner with us in providing your child’s education. Our school is a free, public charter schools that does not discriminate on the basis of race, creed, national origin, ethnicity, religion, gender, sexual orientation, mental or physical disability, special needs, English language proficiency, athletic ability, or academic achievement.
Student


First Name: Middle Name:

Last Name:


Student Email:


Date of Birth: / /

Age:

Gender: (select one)


Current Grade (2015-2016):

Name of Current School:


group 303group 300Entering Grade (for 2016-2017)
Does this student have a sibling already attending the selected school? Y/N
If so, please list the name(s) and grade(s) of the sibling(s):
Parent / Guardian Information


Name

Relationship to Student:


Address:
City, State, Zip:
Home Phone: Work Phone: Cell Phone:
Email address:


group 298group 296Parent/Guardian Signature Date


MA Student Registration and Directory Release Form 2016-2017

group 278School Office Use Only


Student ID Number

Grade

Entry Date _/ /

Bus Number



Parents/Guardians: Please fill out both sides of this registration form for your student. Please print neatly.

STUDENT INFORMATION

Student’s Legal Name:

Last First Middle

Date of birth _/ _/ Sex (M or F) Social Security Number - -


Student’s Address Apt. _ Zip Code

Ethnicity:

Am. Ind./Alaskan Native

Asian/Pacific Islander

Black (not Hispanic)

Hispanic

White (not Hispanic)

Other

History:

Has the student ever attended school in Louisiana? (Y/N)

Has the student ever attended an MA school? (Y/N) Last school attended:



School Name: District:

City: State: Zip: Is this student the subject of a court or custody order? (Y/N) If yes, please provide a copy of the order to the school.



Language:

-Spoken at home:

-First spoken by student:

-Most often spoken by student:



Exceptional Student Services:

Has this student ever received services as an Exceptional Student? _ (Y/N) If yes, please indicate the student’s exceptionality: Gifted Talented Other:




PARENT/GUARDIAN INFORMATION
Last Name First Name Relation

Address Apt. Zip Code Phone Numbers:

Does the student reside at this address? (Y/N)



Home Cell Work
Last Name First Name Relation

Address Apt. Zip Code Phone Numbers:

Does the student reside at this address? (Y/N)



Home Cell Work
Person with whom the student lives if not the parent/guardian:

Last Name First Name Relation



Address Apt. Zip Code Phone Numbers:

Does the student reside at this address? (Y/N)



group 261Home Cell Work
group 244TRANSPORTATION

Does your child need a bus stop? (Y/N) If yes, you must fill out a bus stop request form.

People authorized to pick up student:

Name_ Home Phone Work Phone

Name_ Home Phone Work Phone Name_ Home Phone Work Phone



EMERGENCY CONTACTS
Name_ Home Phone Work Phone Name_ Home Phone Work Phone Name_ Home Phone Work Phone


Student’s Doctor/Clinic Phone Number

Hospital of Choice



Does the student have any special medical conditions/allergies/procedures of which we should be aware? Please list:


group 225ELECTRONIC COMMUNICATION SYSTEM: I hereby understand that students of the Mentorship Academy High School will be granted access to the system’s electronic communications system which includes access to the Internet and Worldwide Web. This access is a privilege, not a right. The system may suspend or revoke a system user’s access upon violation of system policy and/or administrative regulations regarding acceptable use or upon written parental request to the campus School Director.
I further understand that the Mentorship Academy will not publish my child’s individual photograph, video, and/or last name

without my written permission.


STUDENT’S NAME
PARENT/GUARDIAN SIGNATURE DATE


group 216PARENT E-MAIL ADDRESS (OPTIONAL): The Mentorship Academy would like to communicate with you via e-mail should you wish. Provision of an e-mail address is not required. If you do not provide an address, the system will continue to communicate with you in its regular manner to assure continued provision of vital and important information.
My e-mail address is _
STUDENT’S NAME
PARENT/GUARDIAN SIGNATURE DATE


group 207DIRECTORY INFORMATION: The Mentorship Academy regularly receives requests for directory information on students enrolled in the System. Directory information includes, but is not limited to, information such as student name, address, telephone number, date and place of birth, photographs, participation in sports, grade level, dates of attendance, enrollment status and e- mail address.
I GIVE I DO NOT GIVE permission to release student directory information.
STUDENT’S NAME
group 198PARENT/GUARDIAN SIGNATURE DATE


group 189All of the information given on this form is correct.
PARENT/GUARDIAN SIGNATURE DATE




MA Health Services Form 2016-2017

Please fill out this entire form. This information will be kept confidential.




Student’s Legal Name:

Last

Date of birth _/ _/


First Middle Social Security Number - -

Student’s Address Apt. Zip Code


group 187group 185Contact Person Last Name Address
First Name

group 183Apt.


group 181Zip Code
group 179Relation

group 177group 175Does the student reside at this address? Cell
group 173group 171Work

(Y/N) Phone Numbers: Home




group 169group 167group 165Contact Person Last Name Address
First Name

group 163Apt.


group 161Zip Code
group 159Relation

group 157group 155Does the student reside at this address? Cell
group 153group 151Work

(Y/N) Phone Numbers: Home




group 149Other Emergency Contact _ Home phone Work phone

Student’s Doctor/Clinic Doctor’s phone Clinic’s phone

Special medical conditions/allergies/procedures of which the school should be aware:
group 147Medicines taken regularly at home: Medicines taken regularly at school: Does the student have:

Private Insurance (Y/N) Medicaid (Y/N) LACHIP (Y/N)



group 138Does the parent/guardian request insurance information? (Y/N)

All of the information given on this form is correct.


PARENT/GUARDIAN SIGNATURE DATE

STUDENT HEALTH SERVICES: I understand that Health Care Centers in Schools/EBRPSS School Health Team (“Healt h Team”) will provide school health services in cooperation with Mentorship Academy (MA) staff as outlined in the attached summary, and give permission for the Health Team, or any MA employee or any other staff under the guidance of the Health Team, to provide the described services to the student as he/she may require while present in school. I understand that, if the student has a ser ious injury or illness, I will be contacted and the physician/clinic shown on this form and/or Emergency Medical Services (EMS) may be

contacted if necessary. I understand and agree that neither Health Care Centers in Schools nor MA nor their staff will be responsible for any cost involved if the student needs emergency medical care. I understand and agree that, in order to provide a coordinated system of care, the health team or MA employee may exchange health care information about the student with the student’s physician or other health care providers, upon approval by me. I understand and agree that the Health Team may share the student’s health care information with MA personnel, in accordance with protocol, in order to provide appropriate attention to the Student’s health needs. I further understand that my signature approves an MA employee to give permission for my child to be treated in the event that I am not able to be reached for approval.
PARENT/GUARDIAN SIGNATURE DATE


MA Parental/Legal Guardian Media Consent Form 2016-2017

I hereby consent to the use of any photographs/video tape taken of my child by the Mentorship Academy or the media for the purpose of advertising or publicizing events, activities, facilities and programs of the Mentorship Academy in newspapers, newsletters, website, other publications, television, radio and other communications and advertising media.


By law, the Mentorship Academy protects the privacy of the students and is prohibited from releasing students’

personal information. From time to time representatives of the news media are invited to campus to cover events at our

schools. When this happens there is a possibility your child/children may be photographed, videotaped, or interviewed for a news story.


Please mark one of the choices below and return to school.
Yes, I allow my child/children to be identified in any good news Mentorship Academy publication.
No, I do not want my child/children identified in any good news Mentorship Academy publication.
PLEASE PRINT
Student’s Name:
Address:
City:
State/Zip:
Signature:
Parent or Guardian if above person is under 18:
Parent/Guardian’s Name:
Address:
City:
State/Zip:
Signature: Date:







Louisiana Student Residency Questionnaire Form
Louisiana School District School_

Your child may be eligible for additional educational services through Title I Part A, Title I Part C-Migrant, and/or Title X, Part C, Federal McKinney-Vento Assistance Act. Eligibility can be determined by completing this questionnaire.

group 691. Where are you and your family currently staying? Check one box.

Section A

Rent/own my own home.

STOP: If you rent/own your own home, sign under item 5 and submit form to school personnel.


Section B

Temporarily with another family because we cannot afford or find affordable housing. With an adult that is not a parent or legal guardian, or alone without an adult.



In a hotel/motel.

In a vehicle of any kind, trailer park or campground without running water/electricity, abandoned building or substandard housing.

In an emergency/transitional shelter. Other

CONTINUE: If you checked a box in Section B, complete the remainder of this form.

For School Use Only: Doubled-Up Doubled-Up/

Unaccompanied Youth Hotel/Motel Unsheltered

Sheltered

Unknown




2. Have you moved in the past 3 years to seek work as a paid laborer in any type of farming (sod, dairy, chicken, vegetable, citrus, or other) or fishing? (Check One)Yes No

3. If you checked a box in Section B, your child/children may be eligible for additional educational services through

Title I, Part A, Title I Part C-Migrant, or Title X, Part C- Federal McKinney-Vento Assistance Act.

Student(s) Name

First Last


S.S.#

M/F

D.O.B.

Grade

School Name





























































































4. Would you like to be contacted by a member of the school system’s Education for Homeless Children and Youth

program staff? Yes No

5. The undersigned certifies that the information provided above is accurate.


group 67Print Parent/Guardian Name/Adult Caring for Student Signature Date

group 65(Area Code) Phone number Street Address City State Zip
*****************************************************************************************************************************************************************************

School Use Only



Free or Reduced Price Meals Form submitted/signed

Referral Form completed/submitted

group 63Print School Contact Title Signature (required) Date (Revised 4/06)

group 61group 59group 57group 55group 53group 51group 49group 47group 45group 43group 41group 39group 37group 35group 33group 31group 29group 27group 25group 23group 21group 19group 17group 15group 13group 11
MA Point of Contact Communication Sheet 2016-2017

group 8group 6group 4group 2(Office Use Only)


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