SUMMIT LEADERSHIP ACADEMY HIGH DESERT
PRE-REGIGSTRATION CHECKLIST
Student: ________________________________________________________
Grade: _________
Date: _______________ Academy of Interest: __________________________________________
Step 1: Pre-Registration Information
1. ____Pre-Registration Application Complete by parent or guardian
2. ____ Unofficial Transcript
____ Attendance Record
____ Discipline
__IEP
Approval: ______________________________________ Date: __________________
Step 2: Assessments/Evaluation
1. __________ STAR Reading Results
2. __________ STAR Math Results
3. __________ Essay
Comments:
______________________________________________________________________
4. Review of Transcripts: (# of units & grade level)
______________________________________________________________________
5. Review of Discipline Record:
______________________________________________________________________
6. Amount of time between enrollments: _____________
7. Attended Alternative Education Program (indicate where) __________________
Approval: ______________________________________ Date: __________________
Summit Leadership Academy – High Desert
Application Packet
Grade ____
Student’s Name:
Last Name
First Name
Middle Name
Student’s Social Security # ____________________ Birth Date _________ Phone _______________
Address ________________________________________ City __________________ Zip ________
Student lives with:
Mother’s Name _____________________________________ Circle one: Mother Step Mother Guardian
Address ___________________________________________ City _________________ Zip _______
Home Phone _______________________________ Cell Phone ______________________________
Place of Business ___________________________ Work Phone ____________________ Ext. _____
Father’s Name _____________________________________ Circle one: Father Step Father Guardian
Address __________________________________________ City _________________ Zip ________
Home Phone _______________________________ Cell Phone ______________________________
Place of Business ___________________________ Work Phone _____________________ Ext. ____
Who has legal custody of this student? ___________________________________________________
Yes No
Are active restraining orders in place?
Yes No
Are there any legal/custody papers on file?
Parent/Guardian Highest Education Level
(Please check only one per parent/guardian):
Father
Mother
Guardian
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
14 Not a high school graduate
13 High school graduate
12 Some college (includes A.A. /A.S)
11College graduate
10 Graduate school/post graduate training
15 Decline to state
Please answer the following questions:
1. Has this student ever been enrolled in a special education program? Yes _____ No _____
a. If so, please indicate when: ____________
2. Is this student currently enrolled in a special education program? Yes _____ No _____
a. If so, please indicate which program: RSP___ SDC ___ 504 Plan ___ Speech ___Other ___
3. Does this student have an Individualized Education Plan (IEP)? Yes _____ No _____
4. Does this student have health issues that prevent participation in physical activities? Yes ___ No ___
As defined by the federal government, race is different than ethnicity. Please answer both questions.
Ethnicity: Is the student Hispanic or Latino (Please circle one) Yes or No
Race (optional): Please circle all that indicate the student’s race. Race information may be of assistance to
identify the student for certain programs or scholarships.
(100) American Indian/Alaskan (207) Cambodian
(399) Other Pacific Islander
(206) Laotian
(201) Chinese
(299) Other Asian
(400) Filipino
(202) Japanese
(301) Native Hawaiian (500) Hispanic/Latino
(203) Korean
(302) Guamanian
(600) African American
(204) Vietnamese
(303) Samoan
(700) White
(205) Asian Indian
(304) Tahitian
(999) Decline to State
Where is your child/family currently living? (Check one box only) This information will be used to
determine if your child qualifies for additional assistance under the “No Child Left Behind Act of
2001.” In a single family residence___
In a motel, car or campsite___

In a foster care placement or group home___
In a shelter or transitional housing program___
With more than one family in a house or apartment due to economic hardship.
Income: Number of people living in household._________.
Approximate household yearly income (Please check one)
0-$20,000_____ $20,000-$30,000____ $30,000-$40,000___ $40,000-$50,000___$50,000-$60,000___$60,000-$70,000
$70,000-$80,000___$80,000-$90,000___$90,000-$100,000___ More than $100,000___
We understand the following information is sensitive. Please be assured that your answers to these questions are kept
completely confidential. Information gathered here is use only as part of a grand total of our school, and NOT as individual
pieces of information. Providing accurate information here gives the school and all students the opportunity for increased
funds, scholarship and assistance. Please ask the school office if you have any questions
Emergency Contacts
Other responsible persons (18 years or older) that can pick-up or be called in case of an emergency
Name __________________________________________ Relationship ________________________
Phone ___________________________________ Cell Phone ________________________________
Name __________________________________________ Relationship ________________________
Phone ___________________________________ Cell Phone ________________________________
Name __________________________________________ Relationship ________________________
Phone ___________________________________ Cell Phone ________________________________
It is requested that you complete the information below so that if your child requires a visit to the
hospital while under the supervision of the school, this will allow the hospital to treat the injury.
Family Doctor _______________________________ Phone _________________________________
Address ____________________________________ City _____________________ Zip __________
Health Plan/Insurance Co. ________________________________ Policy/Group # _______________
My child is allergic to the following medications/food/insect bites:
_________________________________________________________________________________
My child takes the following medications at home _________________________________________
My child takes the following medications at school ________________________________________
My child has the following health problems:
__________________________________________________________________________________
I, the undersigned parent or guardian, do hereby grant permission for my child (student name),
___________________________, who hereinafter shall be re referred to as “participant,” to
participate in Summit Leadership Academy High Desert. In order that said participant may receive
necessary medical treatment in the event of injury or illness, I hereby hold the Principal, the School
and any Representatives harmless in the exercise of this authority. Parent Initials ______
I further acknowledge, understand and agree that in taking part in this program there is the possibility
of physical illness or injury (minimal, serious, or catastrophic) and the participant is assuming the risk
of such injury by participating. Parent Initials ______
I further agree to hold harmless Summit Leadership Academy High Desert, including the Directors,
Officers, Staff Employees and Volunteers of Summit Leadership Academy, for illness or injury
incurred by participating during the course of the program. Parent Initials ______

Parents Rights
I have read the information on this form and understanding its content. My signature verifies that I
have been informed of my rights as a parent/guardian of a charter school student. My signature DOES
NOT indicate consent to participate in a particular program. I will send written notice to the school of
any specific objections I have regarding my student’s participation in a particular program or service.
I understand that the health information may be shared verbally or in writing with the school district
personnel.
Signature of Parent or Guardian ______________________________________Date ___________
Please check one below:
___ I DO NOT OBJECT to the release of directory information
 ___I OBJECT to the release of directory information
As legal custodian of ________________________, a minor, I hereby authorize the principal or
his/her designee, into whose care the aforementioned minor pupil has been entrusted, to consent to any
X-ray, examination, anesthetic, medical or surgical diagnosis, treatment, and/or hospital care to be
rendered to said minor upon the advise if any licensed physician and/or dentist.
I understand that this authorization is given in advance of any required diagnosis, treatment, or
hospital and provides authority and power to the aforementioned agent(s)to give specific consent to
any and all such diagnosis, treatment, or hospital care which a licensed physician or dentist may deem
necessary.
This authorization shall remain effective for the full school year unless revoked in writing and
delivered to said agent(s). I understand that Summit Leadership Academy, its employees and its
Board assume no liability of any nature in relation to the transportation or treatment of said minor. I
further understand that all costs of paramedic transportation, hospitalization, and any examination, Xray, or treatment provided in relation to this authorization shall be my responsibility.
Enrollment Agreement: Summit Leadership Academy High Desert is a school of CHOICE. By
signing this agreement, you affirm that you choose this school over all others that your child is entitled
to attend. No student may enroll in this school that is enrolled in any other school, except under the
provisions of a currently completed co-enrollment agreement being in effect between both schools.
By your signature hereto, you acknowledge the above limitations and do hereby agree that the student
shall not be enrolled in any school that charges tuition of any sort while enrolled at Summit
Leadership Academy High Desert.
I understand that this is an application to enroll in Summit Leadership Academy High Desert and that
the student is not enrolled until all information has been verified, enrollment forms are completed,
signed and dated, and I have received a copy of this form signed and dated by the Principal/Designee
as verification that the student has been accepted for enrollment.
Please note: No student who has been arrested, on probation or parole, expelled, or suspended for
multiple disciplinary violations or numerous suspensions will be admitted.
Parent/Guardian Signature: ____________________________________________ Date ________
Student Signature: _____________________________________________________Date ________
SUMMIT LEADERSHIP ACADEMY HIGH DESERT
FAMILY CODE 6650 CAREGIVER AUTHORIZATION AFFIDAVIT
The caregiver’s authorization affidavit shall be in substantially the following form: Caregiver’s Authorization Affidavit
Use of this affidavit is authorized by Part 1.5 (commencing with Section 6650) of Division 11 of the California Family Code
Instructions: Completion of items 1-4 and the signing of the affidavit are sufficient to authorize enrollment of a minor in
school and authorization school related medical care. Completion of items 5-8 is additionally to authorize any other
medical care. Please print clearly.
The minor named below lives in my home and I am 18 years of age of older.
1. Name of Minor: __________________________________________________________________
2. Minor’s birth date: ________________________________________________________________
3. My name (adult giving authorization):_________________________________________________
4. My home address: ________________________________________________________________
5. My date of birth: _________________________________________________________________
6. My CA Driver’s License or Identification number: ______________________________________
7. I am a grandparent, aunt, uncle, or other qualified relative of the minor (see the bottom of this page
for a definition of “qualified relative”)
8. Check one or both (for example, if one parent was advised and the other cannot be located):
_____ I have advised the parent(s) or other person(s) having legal custody of the minor of my intent to
authorize medical care and have no objection.
_____ I am unable to contact the parent(s) or other person(s) having legal custody of the minor at this
time, to notify them of my intended authorization.
WARNING:
Do not sign this form if any of the statements above are incorrect or you will be committing a
crime punishable by a fine, imprisonment, or both.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true
and correct.
_____________________________________
Parent/Guardian Signature
___________
Date
FAMILY CODE 6650 “QUALIFIED RELATIVE”
Notices:
1. This declaration does not affect the rights of the minor’s parents or legal guardian regarding the care, custody and control of the minor, and does not
mean that the caregiver has legal custody of the minor.
2. A person who relies on this affidavit has no obligation to make any further inquiry or investigation.
3. This affidavit is not valid for more than one year after the date on which it is executed.
4. This affidavit addresses school residency only and does not allow caregiver access to records.
Additional Information:
To Caregivers:
1. “Qualified relative,” for the purposes of item 5, means a spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half brother, half sister,
uncle, aunt, niece, nephew, first cousin, or any person denoted by the prefix “grand” or the spouse of any persons specified in the definition even after the
marriage has been terminated by death or resolution.
2. The law may require you, if you are not a relative or a currently licensed foster parent, to obtain a foster home license in order to care for a minor. If
you have any questions, please contact your local department of social services.
3. If the minor stops living with you, you are required to notify any school, health care provider, or health care service plan to which you have given this
affidavit.
4. If you do not have the information requested in item 8 (CA driver’s license or identification), please provide another form of identification such as
your social security number or Medi-Cal card.
To School Officials:
1. Section 48204 of the Education Code provides that this affidavit constitutes a sufficient bases for determination of residency of the minor, without the
requirement of a guardianship or other custody order, unless the school district determines from actual facts that the minor is not living with the caregiver.
2. The school district may require additional reasonable evidence that the caregiver lives at the address provided in item 4.
To Health Care Providers and Health Care Service Plans:
1. No person who acts in good faith reliance upon caregiver’s authorization affidavit to provide medical or dental care, without actual knowledge of facts
contrary to those stated on the affidavit, is subject to criminal liability or civil liability to any person, or is subject to professional disciplinary action, for
such reliance of the applicable portions of the form are completed.
2. This affidavit does not confer dependency for health care coverage purposes.
SUMMIT LEADERSHIP ACADEMY HIGH DESERT
CONSENT TO PHOTO
________________________________
Name of Student
During the school year our students might participate in school projects which may include
videotaping or photographing for the school yearbook or newsletter or local publications. These are
exciting opportunities for the students and their classmates. In order to allow such participation, please
sign below indicating that permission is given.
PLEASE CIRCLE ONE.
I hereby GIVE/DO NOT GIVE my consent to Summit Leadership Academy High Desert to include
my student in photos or videotapes at Summit Leadership Academy or other school-related activities.
I understand that these pictures are for educational purposes, public interest or informational purposes
through media of radio, television, newspaper or film.
_____________________________________________
Parent/Guardian Signature
__________
Date
VIDEO/CLASSROOM PERMISSION
As part of the SLAHD class curriculum your student will be watching various movies, clips of
movies, or documentaries that may include some type of “PG-13/R” rated material.
The items that will be shown may contain some type of violence or vulgarity due to the nature
of the items being shown. It is the intent of the instructors to bring to life items that relate the subject
matter that they are studying through these films. The movie(s) will be stopped at appropriate time so
discussion can be shared and to insure that the students understand why these films are being shown.
Safety is number one in these classes and appropriate supervision will be taken at all times.
If you have any questions or concerns regarding the contents of the films, please contact any
staff member at, 949-9202. You are welcome to come in and view these films prior to them being
shown, or sit in the classroom to see what your student is being taught. Please sign the lower portion
of this letter with your student(s). If this form is not signed and dated, your student will not be
allowed to watch the film(s).
[ ]
Yes, I give my son/daughter __________________________ permission to watch the films
used for educational purposes. I understand that the film, film clip, or documentary will contain
some “PG-13/R” rated material and discussion will follow the film.
[ ]
Yes, I give my son/daughter __________________________ permission to participate in
the self-defense/handcuffing classes/activities that are offered at the school.
[ ]
No, I do not want my son/daughter __________________________ to watch the films, film
clip, or documentary that contain any “PG-13/R” rated material.
[ ]
No, I do not want my son/daughter __________________________ to participate in the
self-defense/handcuffing classes/activities at the school.
_________________________
Print Parent/Guardian Name
_________________________
Signature
__________
Date
Summit Leadership Academy-High Desert
Home Language Survey
Estudio Del Idioma Del Hogar
The California Education Code requires schools to determine the language(s) spoken at home by each student.
This information is essential in order for schools to provide meaningful instruction for all students.
El Codigo de Educacion de California requiere que las escuelas determinin los idiomas que se hablan en el
hogar de cada estudiante. Esta informacion es esencial para que las escuelas puedan proporcionar instruccion
significativa a todos los estudiantes.
Your cooperation in helping us meet this important requirement is requested. Please answer the following
questions:
La pedimos su coopercion en ayudamos a cumplir este requisito importante. Por favor conteste las sigulentes
preguntas y haga que su hijo o hija devuelva esta forma a su maestro(a). Gracias por su ayuda.
Student: ___________________________________________ Grade: _____ Age: _____
Address: ________________________ City: _____________________ Zip: __________
D.O.B. __________ Birthplace: _____________________________ Sex M ____ F ____
Student resides with: __________________________________ Relationship: _________
Work #: Father: __________________________ Mother: _________________________
(Or guardian)
Emergency contact: ________________________________ Phone #: _______________
1.
Which language did your son/daughter learn when he or she first began to talk?
Cuando su hijo(a) empezo a hablar Cual idioma aprendio primero?
_________________________________________________________________
2.
What language does your son or daughter most frequently use at home?
Cual idioma usa principalmente su hijo(a) cuando conversaen la casa?
__________________________________________________________________
3.
What language do you use most frequently to speak to your son or daughter?
Cual idioma usa Ud. Con mas frecuencia cuando habla con su hijo(a)?
__________________________________________________________________
4.
Name the language most often spoken by the adults at home:
(Cual idioma hablan los adultos con mas frecuencia en la casa?)
__________________________________________________________________
5.
Where was he/she born? Donde nacio el nino?
__________________________________________________________________
When did he/she enter the U.S.? Cuando entro el nino a los Estados Unidos?
__________________________________________________________________
6.
____________________________________________________
______________
Signature of Parent/Guardian (Firma del Padre O Tutor)
Date
SUMMIT LEADERSHIP ACADEMY HIGH DESERT
MANDATORY STATEWIDE TESTING INFORMATION
The following information is required for the mandatory statewide testing. Please fill out and return
with the enrollment packet. This information is kept confidential.
Student Name: _________________________ Date of Birth: _______ Sex: M F Grade: _____
Grade level when entered Hesperia Unified School District for the first time: __________
Grade level when entered Summit Leadership Academy for the first time: ____________
Please indicate the home language (circle one):
11
56
12
42
61
13
03
36
54
20
39
15
16
05
17
18
19
43
21
Arabic
Albanian
Armenian
Assyrian
Bengali
Burmese
Cantonese
Cebuano (Visayan)
Chaldean
Chamorro
Chaozhou (Chiuchow)
Dutch
Farsi (Persian)
Filipino (Tagalog)
French
German
Greek
Gujarati
Hebrew
22
23
24
25
26
27
08
09
50
04
51
47
10
07
48
44
49
40
41
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Japanese
Khmer (Cambodian)
Khmu
Korean
Kurdish
Lahu
Lao
Mandarin (Putonghua)
Marshallese
Mien (Yao)
Mixteco
Pashto
Polish
06
28
45
29
30
52
60
01
46
32
57
53
34
33
38
35
02
99
Portuguese
Punjabi
Romanian
Russian
Samoan
Serbo-Croatian
Somali
Spanish
Taiwanese
Thai
Tigrinya
Toishanese
Tongan
Turkish
Ukrainian
Urdu
Vietnamese
All other non-English languages
If you are Asian or a Pacific Islander, please check one of the following:
___Chinese
___Japanese
___Vietnamese
___Guamanian
___Laotian
___Cambodian
___Other Asian
___Hawaiian
___Asian Indian
___Tahitian
___Other Pacific Islander
___Korean
___Samoan
TERMS AND CONDITIONS OF INTERNET RESOURCES AGREEMENT
Personal Responsibility: As a student of Summit Leadership Academy, I am a representative of this
school and I will accept personal responsibility for reporting any misuses of the network to the system
administrator. Misuse can come in many forms, but it is commonly viewed as any message(s) sent or
received that indicates or suggests pornography, unethical or illegal solicitation, racism or sexism,
when using the network.
I HAVE READ AND UNDERSTAND THIS PROVISION.
User: _____ (initial)
Acceptable Use: The use of my assigned account must be in support of education and research. I am
personally responsible for this provision at all times when using the electronic information service.
Use of other organizations’ networks or computing resources must comply with rules appropriate to
that network.
Transmission of any material in violation of any United States or other state organization is prohibited
and includes, but is not limited to, copyrighted material, threatening or obscene material or material
protection trade secret.
Use of commercial activities by for-profit institutions is generally not acceptable.
Use of product advertisement or use of electronic information resources can be a violation of local,
state and federal laws that I can be prosecuted for violating those laws.
Use of chat rooms and community/social websites are prohibited.
I READ AND UNDERSTAND THIS PROVISION.
User: _____ (initial)
Privileges: The use of the information system is a privilege, not a right and inappropriate use will
result in cancellation of those privileges.
I READ AND UNDERSTAND THIS PROVISION.
User: _____ (initial)
Network Etiquette and Privacy: You are expected to abide by the generally accepted rules of
network etiquette. These rules include, but are not limited to, the following:
Be polite. Never send, or encourage others to send, abusive messages.
Use appropriate language. Remember that you are a representative of Summit Leadership Academy.
Never swear, use vulgarities, or any other language, illegal activities of any kind are strictly forbidden
I READ AND UNDERSTAND THIS PROVISION.
User: _____ (initial)
Student Name: _______________________________________________
_______________
Print Name
Date
__________________________________________________________________________________________________
CELL PHONE POLICY
No student is permitted to use a cell phone or any other electronic device on campus during school
hours. Cell phones interrupt and can distract from the learning process. Camera phones are not
permitted on campus. This is for the safety of our student body. All cell phones seen or heard on
campus during school hours will be confiscated and ONLY released to a parent or guardian. Should a
call need to be made during school hours, it must be done in the school office.
As a student of Summit Leadership Academy High Desert, I have read the cell phone policy, and I
understand that I will be expected to follow this policy.
______________________________
______________________________
_____
Student Printed Name
Student Signature
Date
______________________________
______________________________
_____
Parent/Guardian Printed Name
Parent/Guardian Signature
Date
Summit Leadership Academy-High Desert
Student Contract
As a student of SLAHD, I understand that I will be expected to follow all program rules, and
that I will accept full responsibility for any and all SLAHD equipment or items issued to me. I
understand that as a student of the Summit Leadership Academy High Desert, I may from time to time
be required to purchase additional or optional items at my expense. I further understand that if I go on
a school sponsored field trip, I will be required to bring my own meal. I also understand that if I do
not maintain a passing grade of at least a “C” or 70 percent in all academic areas, I may be requested
to attend tutoring. Finally, I understand that I can be placed on suspension, a behavioral contract, or
be formally removed from the SLAHD for improper behavior.
I understand that I must wear the proper clothing described by the dress code every day to
school and comply with all grooming standards. I also know that I can be formally removed from the
SLAHD for continuous or severe behavior problems. Furthermore, I understand that I may be put on a
student behavioral contract for repetitive behavioral problems. I also understand that I am responsible
for making up any missed schoolwork within five school days, and that I am financially responsible
for any vandalism to the school property, school equipment/utilities, staff, or student property that I
may cause.
I have read and fully understand the School Rules and Handbook and I agree to abide by them.
I also understand that failure to follow these rules and the handbook may lead to my suspension or
formal removal from SLAHD.
SUMMIT LEADERSHIP ACADEMY HIGH DESERT
RECEIPT OF STUDENT-PARENT HANDBOOK
To ensure the safety of our students, staff and visitors, we want to instill the importance of the rules
and regulations set forth in the Student-Parent Handbook.
I, ________________________________ read and understand the information in the
Student’s Printed Name
Summit Leadership Academy Student Handbook and I agree to comply with each policy, procedure,
and standards described within.
_________________________________
Student’s Signature
______________
Date
I, ________________________________ read and understand the information in the
Parent/Guardian Printed Name
Summit Leadership Academy Student Handbook and I agree to comply with each policy, procedure,
and standards described within.
_________________________________
Parent/Guardian Signature
______________
Date
Summit Leadership Academy – High Desert
REQUEST FOR CUMULATIVE RECORD
_____________________________
Students Name
______________________________
Date of Birth
This Pupil is Now Enrolled in Grade _____ at:
Summit Leadership Academy – High Desert
12850 Muscatel St
Hesperia, CA 92345
(760) 949-9202 Fax (760) 949-9257
Please send complete cumulative records and complete transcript of the completed/in progress at your
school. Include test data, health records, and a key to the grading system. Additionally, include
records that resulted in the pupil’s suspension or expulsion from your school for the previous 3 years
and a key listing the specific codes.
Thank you,
_________________________________________
Registrar’s Signature
____________________
Date
________________________________________
Parent’s Signature
____________________
Date
SUMMIT LEADERSHIP ACADEMY HIGH DESERT
STUDENT SEXUAL HARASSMENT POLICY AND CONTRACT
As a student enrolled in Summit Leadership Academy High Desert it is important that you and your
parent(s)/guardian(s) understand the state and federal law, as well as our policy on Sexual Harassment.
It is very specific.
SEXUAL HARASSMENT DEFINED BY LAW
Sexual harassment, as defined by both state and federal law is forbidden. Whether it is a faculty
member, administrator, staff member or student, you can be held liable in a court of law if your
personal conduct either written, verbal or through your action(s), violate the provisions of the Fair
Employment and House Act (hereafter called, the “Act.”) According to the Act, harassment is defined
as sexual harassment, gender harassment, and harassment based on pregnancy, childbirth, or related
medical conditions. Sexual harassment as defined by the Act is unwanted sexual advances, visual,
verbal or physical conduct of a sexual nature. This definition includes many forms of offensive
behavior and includes gender-based harassment of a person of the same sex as the harasser. The
following is a partial list of prohibited behavior:







Unwanted sexual advances
Making or threatening reprisals after a negative response to sexual advances
Visual conduct to include looking intently, making sexual gestures, displaying of sexually
suggestive objects, pictures, cartoons, or posters
Verbal conduct such as making or using derogatory comments, abusive words, slurs, or
jokes
Verbal sexual advances or propositions
Verbal abuse of a sexual nature, graphic verbal commentaries about an individual’s body,
sexually degrading words used to describe an individual, suggestive or obscene letters,
notes, or invitations
Physical conduct of a sexual nature such as touching another person inappropriately,
assault, impeding or blocking movements
SUMMIT LEADERSHIP ACADEMY’S SEXUAL HARASSMENT POLICY FOR STUDENTS
Since the law specifically forbids sexual or gender harassment of any sort, it is our policy that any
student who harasses another student, faculty or staff member, regardless of gender, either willfully or
innocently, will be subject to disciplinary action. These actions could range from a verbal
admonishment to removal from Summit Leadership Academy and to possibly include either civil or
criminal actions or both. Our policy is clear: Sexual harassment of any sort will not be tolerated.
By signing below, this student and parent understand (1) the Summit Leadership Academy policy for
sexual harassment, (2) the implications if the policy is violated and (3) that this student and parent
could be held civilly or criminally liable or both.
_________________________________________________
Parent/Guardian Signature
_______________
Date
_________________________________________________
Student Signature
_______________
Date