Application Packet: Steps for Enrollment
Items included in this packet to be submitted:
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Student Information
Parent/Guardian Information
Educational History
Child Pick Up/Emergency Information
Family Information
How did you hear about us
Parent/Guardian Commitment
Emergency Medical Authorization Form
Media Release
Copies of documents to be sumitted:
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Birth Certificate: A copy of a baptismal certificate, passport or naturalization papers are
acceptable.
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Social Security Card: Copy of student’s Social Security Card.
Immunization Records: Written evidence that student has had all the required
immunizations.
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Proof of Residency: Must be a utility bill, a copy of current lease or a mortgage statement
only.
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Copy of Photo ID of Custodial Parent Enrolling Student
Additional documents to be submitted if applicable:
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Custody, Divorce, Adoption Papers, or Guardianship Papers (if applicable):
Proof of
custody MUST be presented for any student for which custody has been determined by a court.
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Special Needs Documentation (if applicable):
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Transcript:
Please provide the most recent Individualized
Education Program (IEP), Evaluation Team Report (ETR), Multifactored Evaluation (MFE) and/or 504 Plan.
An unofficial transcript from the last school(s) attended are acceptable.
Thank you for your cooperation in providing the requested documentation.
Return the application form and necessary documents to Quest Community School at 12000 Snow
Road Suite 4/5, Parma, OH 44130. If you have any questions or need assistance with forms, please
call Darla Thompson at 216-220-4412.
2015-2016 SCHOOL YEAR
REGISTRATION/ENROLLMENT APPLICATION
Student Information:
Date
Grade Enrolling_____________________
Name of Student:
(First)
(Middle)
Address___________________________ Apt.#
(Last)
City
Zip Code ___________________
(Bring in a copy of lease agreement or utility bill for Proof Of Residency)
Primary Phone #
Alternate Phone#
Social Security # (optional):
-
-
Email:
Birth Date:
Gender:
 Male  Female
(Last four digits required)
Birth Mother’s Maiden Name:
Ethnicity: Is the student of Hispanic/Latino Origin?
 Yes
 No
Race:  White  Black  Hispanic  Asian  American Indian/Alaskan Native  Pacific Islander
 Multi-racial If Multi-racial, please circle one of the following:
 White  Black  Hispanic  Asian American Indian/Alaskan Native  Pacific Islander
Native Language:
1. Is a language other than English used in the home?  Yes  No If yes, what language ____________________________
2. Does the student have a first language other than English?  Yes  No
3. Does the student most frequently speak a language other than English?  Yes  No If yes, what language ______________
4. If student speaks a language other than English or was born outside of the United States, please give the month and year the student
FIRST entered the United States:_________________________________________________
If the student was born outside of the United States, in which country was he/she born? _______________________
If the answer to the questions above is a language other than English indicate the native language in EMIS and proceed to assess the student’s ELP
If required, translation services were provided by:
Signature _________________________________________________________ Date___________________________________
Name (please print) _________________________________________________
Parent/Guardian Information:
Name of parents/legal guardians with whom student resides:
__________________________________________________________________________________________________________
(First)
(Middle)
(Last)
(home phone #)
(work phone#)
___________________________________________________________________________________________________________
(First)
(Middle)
(Last)
(home phone #)
(work phone#)
Who does the child live with? (Circle all that apply)
Mother Father Grandmother Grandfather Step-Father Step-Mother Surrogate Guardian Guardian Ad Litem
Other: _____________________________ (Name and relationship to the student)
Who has legal custody of the student?  Both Parents  One Parent (Mother or Father) Other: _____________________________
Name and address of CUSTODIAL PARENT NOT residing with student: _______________________________________________
Please list any CUSTODIAL ISSUES: ___________________________________________________________________________
A complete set of custody and/or guardianship papers must be on file with the school office if applicable.
Educational History:
Does the student have a current or active Individual Education Plan (I.E.P.)?  Yes  No
Did the student ever have an I.E.P?  Yes  No
If yes, please provide a copy of the student’s I.E.P. and Evaluation If yes, what school year? ________________________________
Does the student have a current or active 504 plan?  Yes  No
If yes, please provide a copy of the student’s 504 Plan
Public School District of Residence:
Previous School Phone #:
Name of School Last Attended:
Withdrawal date from previous school:__________________________
Previous school address:
How long did student attend previous school district?_________________
Last grade attended at previous school:
Has student officially withdrawn from previous school?  Yes  No
Did the student attend pre-school?  Yes  No How many years or months did student attend pre-school? Years ___ Months
Name of pre-school attended:
City:_________________________
Does the student have any medical/health, or other concerns that the school should be aware of? ______________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Child Pick-Up/Emergency Information:
I agree my child may be physically released only to the following person(s). These person(s) may also be called in the event of an
emergency. Proof of identification, in the form of picture ID is required when picking up child(ren). Changes of any release/ contact
selections must be received in written form.
Name
Relationship to
Phone Number
Address
Student
Family Information:
Additional Children under 18 living in the home
Name
How Did You Hear About Us:
(check all that apply)
 Brochure/Flyer
 Internet/Website
Age
 Newspaper
School Attending
 Radio
 Family/Friend
 Previously attended
 Other (Please describe)
Parent/Guardian Commitment:
By signing below I/we agree that my child will abide by and support the Academy rules and regulations, including the Code of
Conduct and all other policies. Although the Parent/Student Handbook will reflect the current policies of the Academy, it may be
necessary to make changes from time to time to best serve the needs of the Academy and its students. I further confirm that the
information provided on this document is true and current. I am the legal guardian or custodian of the above student.
Parent/Guardian:
Date:
(Signature)
(Relationship to Student)
Student:
Date:
(Signature)
This form constitutes withdrawal from:
Parent/Guardian Signature:
______
_______
______
Date:_____________________
Date: _____________________
Emergency Medical Authorization Form
Student Name_________________________________________________________________________
Last
First
Middle
Date of Birth
Home Phone
Home Address
City
School Attending
School Year
Zip_______
Grade_______________
Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or
injured while under school authority, when parents or guardians cannot be reached. This information will be shared, as
necessary, with teachers, bus drivers, administrative staff, health personnel including student nurses, and other school personnel.
Residential Parent or Guardian
Mother’s Name:
Daytime Phone
Cell Phone
Father’s Name:
Daytime Phone
Cell Phone
Emergency Contacts
Name
Relationship to
Student
Daytime Phone
Cell Phone
1.
2.
3.
It is extremely important that you provide ANY pertinent medical history or information about existing conditions that may
affect your child at school.
Medical Information:
Medications:
Allergies:
PART I OR II MUST BE COMPLETED
PART I: TO GRANT CONSENT
PART II: REFUSAL TO CONSENT
I hereby give consent for the following
medical care providers and local hospital to
be called:
Phone Number
Doctor
I do NOT give my consent for emergency medical treatment
of my child. In the event of illness or injury requiring
emergency treatment, I wish the school authorities to take the
following action:
Signature or Parent/Guardian:
Dentist
Medical Specialist
Date:
Local Hospital/Emergency Room
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for:
1) The administration of any treatment deemed necessary by above named doctors, or, in the event the designed practitioner is
not available, by another licensed physician or dentist:
2) The transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the
medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to
the performance of such surgery.
Signature or Parent/Guardian:
Signature or Parent/Guardian:
Date:
Date:
Media Release
Name of Student:
(First)
(Last)
I/We understand that as part of our child’s/my attendance at the Academy; photos, videos, and
quotations may be taken for use in publications and reports about the program. I/We further
understand that members of the news media invited to cover the program may take photos, videos
and quotations.
I/We grant permission to the School and its Board Members, Management Company, employees,
agent and representatives to use such materials for the promotion of the program and to use this
student’s name, photographic likeness, alone or in a group, in any publication, document, TV
production, video or to release said name or likeness to any media outlets including, but not limited
to newspapers, magazines or TV stations for publicity and/or recognition purposes and/or to use this
student’s name and/or photographic likeness, alone or in a group, on the official web site of the
Academy and/or Management Company.
I agree that I and/or my child shall have no right, title, or interest in any photo or videotape covered
by this agreement and waive any right to compensation for such use. I release the Academy, its
Board members, the Management Company, employees, agents, representatives and all
organizations and individuals related to the Academy from any and all liabilities or damages that
result from the use of this student’s name and/or photographic likeness as described above.
 I/We agree to give permission at this time.
OR
 I/We DO NOT give permission at this time.
Parent/Guardian Signature:
Date:_________________