3101 Technology Blvd, Ste A, Lansing MI 48910. Office: (517) 325-5469
Email us at info@lifetechacademy.org or visit our website: www.lifetechacademy.org

Enrollment Application (Part 1)

Learner Information


Parent / Guardian Information


School Information




 

Reason(s) for applying to LifeTech Academy (Check all that apply):

** While preference will be considered, final program placement recommendations will be made after a complete review of assessment data, transcript audit, and learner interview.

Part 2

Additional Contacts


Parent/Guardian/Other 2 (not previously listed)

Parent/Guardian/Other 3 (not previously listed)

Home Language Survey


Please answer the following questions. Select English or write the name of the language used most often.

1. What language did the learner speak when they first began to talk?

Other Language

 
 
 

2. What language does the learner speak most often at home with the parent/guardian?

Other Language

 
 
 

3. What language does the learner speak most often with their friends?

Other Language

 
 
 

4. What language does the parent/guardian use most often when speaking
with the learner?

Other Language

 
 
 
Any learner that indicates a language other than English, must be administered the English language proficiency test to meet federal NCLB Title III regulations.

Identity


1. Ethnicity (Please check one)

2. Race (Please choose all that apply, regardless of what was selected above)

3. Gender:

4. Multiple Birth (twins, triplets, etc.)

What was your birth order?

IEP/504 Status




Rule 340.1721b (5) of the Michigan Administrative Rules for Special Education requires that, for students with an individualized education program in effect at a previous public agency who transfer public agencies within the same school year, the new public agency shall immediately provide a free and appropriate public education. A decision regarding implementation of an individualized education program in accordance with 34 CFR § 300.323 shall be made within 30 school days of enrollment.

Accommodations and Modifications


Part 3

Assistance and Special Circumstances


The learner may be eligible for additional support services to help eliminate educational barriers. Completing this questionnaire will help us make that determination.



A homeless or in transition student is defined as one who lacks a fixed, regular and adequate nighttime residence under one of the following conditions.

2. Please check those which apply to the learner.



4. Please mark all that apply:


5. Which of the following statements best fits your family history?

Part 4

Adjudications and Convictions


Please choose the appropriate option as it relates to the learner shown on this application.



Learner Medical Information and Consent




Please Explain

 
 
 
 

Please Explain

 
 
 

Please Explain

 
 
 

Please Explain

 
 
 

Current Medications

 
 
 

By law, all medications taken during school hours must be stored and logged in the school office.