LSEIA Intent to Enroll

Intent to Enroll

Enrollment Form
Apam, Central Region, Ghana

+233 53 736 6374, +233 55 955 2263 lifesourceelevateintacademy@gmail.com
Preferred Correspondence Language
How many students are you enrolling?*

Parent/Guardian #1
Parent Full Name #1*

First NameLast Name
Relationship to Student*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Number*
Work Number*
E-mail*
Lives with student*

YesNo
Signature*

Clear
Parent/Guardian #2
Parent Full Name #2

First NameLast Name
Relationship to Student
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Number
Work Number
E-mail
example@example.com
Lives with student

YesNo
Signature

Clear

Child #1 Details
Student Full Name #1*

First NameLast Name
Gender
Preferred Language
Grade Level*
Date of Birth*

DayMonthYear
Street Address

Street Address Line 2

Birth CityBirth State / Province

Zip CodeBirth Country
Medical Conditions

Conditions

	Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)

Specify Other Medical Condition

Child #2 Details
Student Full Name #2*

First NameLast Name
Gender
Preferred Language
Grade Level*
Date of Birth*

DayMonthYear
Street Address

Street Address Line 2

Birth CityBirth State / Province

Postal / Zip CodeBirth Country
Medical Conditions

Conditions

	Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)

Specify Other Medical Condition

Child #3 Details
Student Full Name #3*

First NameLast Name
Gender
Preferred Language
Grade Level*
Date of Birth*

DayMonthYear
Street Address

Street Address Line 2

Birth CityBirth State / Province

Postal / Zip CodeBirth Country
Medical Conditions

Conditions

	Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)

Specify Other Medical Condition

Child #4 Details
Student Full Name #4*

First NameLast Name
Gender
Preferred Language
Grade Level*
Date of Birth*

DayMonthYear
Street Address

Street Address Line 2

Birth CityBirth State / Province

Postal / Zip CodeBirth Country
Medical Conditions

Conditions

	Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)

Specify Other Medical Condition

Child #5 Details
Student Full Name #5*

First NameLast Name
Gender
Preferred Language
Grade Level*
Date of Birth*

DayMonthYear
Street Address

Street Address Line 2

Birth CityBirth State / Province

Postal / Zip CodeBirth Country
Medical Conditions

Conditions

	Check all that apply
Asthma
Allergy
Heart Condition
Seizures
Diabetes
Other ( please specify below)

Specify Other Medical Condition

Almost done...
Emergency Contact Information
1. Contact Name *

Relationship to student

Phone Number 1State

Zip Code
2. Contact Name

Relationship to student

Phone Number 1State

Zip Code
Legal restrictions for any parent?

Last Question...
Special Education Agreement
Please choose one of the options below:

Option A: My student has never received Special Education Services of any kind. (Example of a special education service is Speech, RSP, Occupational Therapy, ETC.)

Option B: My student has an special Education Services Plan and I will upload the document so a special education team member can contact me and discuss the needs of my student
Choose one of the Following

Option AOption B
Please verify that you are human*
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