L and J Virtual Academy Registration


IMPORTANT PLEASE READ
This form is to serve as the 1st step toward securing your students spot at the academy.  Next steps, to ensure enrollment, will be followed up with an email.

Please be sure to have a copy of your students report card to turn in, it is mandatory for registration.
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Email *
How did you hear about us? *
How many students will you be registering in the virtual academy? *
What service can we provide for you? *
Required
Student Full Name *
What school is your student registered in full-time? *
Date of Birth *
MM
/
DD
/
YYYY
Current Grade Level *
Student Gender *
Student Race *
Students Street Address, City, State, Zip Code *
List siblings (Please note a registration form must be completed for each sibling listed) provide siblings FULL NAME AND GRADE LEVEL (Type N/A if not applicable) *
1st Parent/Guardian Name *
1st Parent/Guardian Mailing Address *
1st Parent/Guardian Email Address *
1st Parent/Guardian Cellphone Phone Number *
1st Parent/Guardian Home Phone Number *
2nd Parent/Guardian Name
2nd Parent/Guardian Mailing Address
2nd Parent/Guardian Email Address
2nd Parent/Guardian Cellphone Phone Number
2nd Parent/Guardian Home Phone Number
Family Arrangement *
Person(s) authorized to remove child (check all boxes that apply) *
Required
Special Medical or Other needs (Please explain)
Person to be contacted in case of illness, accident, emergency, and authorized to remove the child from the facility in the absence of a parent/guardian. Authorized individuals must be 18 years old or older and present picture identification.  Please include: NAME, PHONE NUMBER AND RELATIONSHIP TO THE STUDENT
Physician Name/Address/Phone Number *
Please initial stating you have read and agreed to each of the following: In consideration of being allowed in any way in the Lewis-Chambliss Group, LLC and J1S Consulting, LLC education program and related events and activities the undersigned agrees to the following:  acknowledge and fully understand that each participant will be engaging in activities that may Involve risk or serious injury; including permanent disability and severe social and economic losses which may result not only from their actions, inactions or negligence, but the actions inaction or negligence of others, the rules of play or the condition of the premises or any equipment used. Further, that there may be risks not known to us or not reasonably foreseeable at this time. To the best of my knowledge, my daughter/son is physically fit to engage in the activity in question. I understand that the Lewis-Chambliss Group, LLC and J1S Consulting, LLC and their employees and agents will exercise reasonable care while my daughter/son is in their custody and care engaging in activities through daily care. I agree to hold the Lewis-Chambliss, LLC and J1S Consulting, LLC and its employees and agents harmless from any and all liability, which may arise while exercising their duty of care, relating to my daughter/son for personal injury or illness that may be suffered or any loss of property that may occur to my daughter/son while participating in L&J Virtual Academy. *
Please initial stating you have read and agreed to each of the following: Authorization for Emergency Care: In case of accident or serious illness, and the school/program is unable to reach me, I hereby authorize the school/program to contact the physician indicated on the application and to follow his/her instructions. If it is impossible to contact this physician, the program may make whatever arrangements necessary to provide care and treatment for my child. In case of accident/ serious illness where the immediate treatment of my child is not necessary, but he/she is unable to reach me, I authorize the school/ program to contact one of the persons indicated on the registration form and ask them to pick up and transport my child. *
Please initial stating you have read and agreed to each of the following: Photo/Media Release: I acknowledge and understand that publicity activities such as interviews, photos, and videotaping may occur.  I consent and permit my child, as a participant in the L&J Virtual Academy and events, to be photographed, videotaped, and/or interviewed for publicity activities.  
Please initial stating you have read and agreed to each of the following: School Records Release Statement: I give my consent for my son’s/daughter’s/ward/’s school records to be accessed by the Lewis-Chambliss Group, LLC and J1S Consulting, LLC.  The data accumulated will be aggregated without identifying any individual child and used to create an academic action plan. *
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