EnrollmentForm – Genesee STEM Academy

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Genesee County's First S.T.E.M Certified School

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Child's Legal Name *

Last, First, Middle

Gender *

Male
Female

Birthdate *

Birthplace (country) *

Entering Grade *

Home Address *

Home Phone

Cell Phone *

Previous School Attended *

(Name, City, State)

Does your child receive Special Education services? *

Yes
No

Does your child receive Speech services? *

Yes
No

Ethnicity *

Hispanic or Latino
Not Hispanic or Latino

Race (please choose all that apply (for state purposes only) *

American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

If not English, what is the primary language spoken in your home?

Parent/Guardian #1 *

Last, First Middle

Relationship *

Address (if different from that listed above)

Email

Work Phone

Home/Cell Phone *

Parent/Guardian #2

Last, First, Middle

Relationship

Address (if different from that listed above)

Email

Work Phone

Home/Cell Phone *

Emergency Contacts - In an emergency, the school may contact and/or release my student to this adult. Please choose adults that can be reached by telephone. Please list persons in order in which you wish contact to be made. *

Name, Phone, Relationship

Single Line Text

Name, Phone, Relationship

Single Line Text (copy)

Name, Phone, Relationship

Medical Information *

Hospital Preference

The following health condition(s) apply to my child

Asthma
Cerebral Palsy
Congenital Abnormality
Heart Condition
Epilepsy/Seizures
Diabetes
ADHD/ADD
Bee Sting Allergy
Cancer/Leukemia
Peanut/Nut Allergy

Other Medical Conditions (please be specific)

Drug Allergies (list)

Other Allergies (list)

Has your child had Chicken Pox? If yes, month/year *

As part of out pest management program, pesticides are occasionally applied. You have the right to be informed prior to any routine pesticide application made to the school grounds and buildings. (In an emergency situation, pesticides may be applied without prior notice.) *

I do not wish to be notified each time a treatment takes place.
I wish to be notified prior to a scheduled treatment inside of the building.
I wish to be notified prior to a scheduled treatment on the outside of the building.

Student Photo/Video Permission *

I hereby grant permission to GSTEMA to use photos, printed names and video footage in school publications, postings in the building, at presentations and on the school website and other social media platforms.
I hereby grant permission to GSTEMA to use photos and video footage in school publications, postings in the building, at presentations and on the school website and other social media platforms.
I hereby grant permission to GSTEMA to use photos and video footage for postings in the building .
I do not wish my child to be photographed.

Consent for Disclosure of Immunization Information to Local and State Health Departments *

I authorize Genesee STEM Academy to release my child's immunization record to the Michigan Department of Health and Human Services and Local Health Department. I understand this information will be used to improve the quality and timeliness of immunization services and to help schools comply with Michigan Law. This includes any immunization information and limited personally identifiable information from the school. I understand that I may withdraw my consent to share this information in writing at any time.
I do not authorize Genesee STEM Academy to release my child's immunization record to the Michigan Department of Health and Human Services and Local Health Department.

Student and Parent Handbook *

I have read the Student and Parent Handbook and understand the expectations

Technology Agreement *

I grant permission for my child to access network services such as electronic mail and the internet. I have read and agree to Genesee STEM Academy's internet procedure and understand that my child's access account can be used to access the internet from computers outside the school community. I understand that some materials on the internet my be objectionable; therefore, I agree to accept responsibility for guiding my child and conveying to them appropriate standards for selecting, sharing and/or exploring information and media.

I understand that it is my child's responsibility to keep track of their property and to use school materials and equipment properly. I understand all reasonable precautions against theft are being taken by the school and the school cannot be held responsible for lost items. I have discussed this responsibility with my child. *

Parent/Guardian Signature

Date

I hereby acknowledge that the information provided on this form is true and accurate. I understand that if anything is found not to be true or accurate, this may result in dismissal of my child from Genesee STEM Academy. I understand that it is my responsibility to notify the school office if and when any of the information on this form changes. *

Parent/Guardian Signature

Date

Phone

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