Student Enrollment Form

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Student Enrollment Form

Welcome Families

Thank you for your interest in Leadership Preparatory Charter School. We are accepting
applications for Kindergarten- 8th Grade.

We look forward to your partnership in ensuring your child receives the academic and character foundation necessary to excel and lead in their communities!

In order to complete the enrollment application process, you must complete the student enrollment forms. Please provide copies of the items listed below to complete the application.

Failure to provide all necessary documents in a timely manner may result in your
student being placed on the admissions waitlist.

Leadership Preparatory Charter School is a tuition-free public school.

There are no academic, financial, or other requirements for admission. Please note the following,
as it pertains to enrollment eligibility:

Children must be 5 years of age on or before August 15, 2022 in order to enroll in
Kindergarten
Children must have completed Kindergarten before enrolling in the 1st Grade

New Scholar Enrollment Packet Checklist

Parent Documentation

Photo ID of parent/guardian
Proof of Home Address (i.e. copy of rent or utility bill)

Student Documentation

Birth Certificate/Passport
Social Security Card
Certificate of Immunization (Note: Must be on Tennessee Department of Health Form)
Previous year report card (Required for grades 1 and up)

Enrollment Forms

New Student Registration Form
Parent/Guardian Contact Information
Request for Permanent Records
Student Health Information
Student Emergency Care Information
Emergency Care Plan
Photo/Video/Media Release Form
Seat Acceptance
Primary Home Language identification Form
Occupational Survey

"*" indicates required fields

1Welcome

2Student Information

3Parent / Guardian Information

4 Request for Permanent Record

5Student Health Information

6Student Emergency Care Info

7Emergency Care Plan

8Media Release Form

Student Information

Name*

First Middle Last

Address*

Address Apt. No City State ZIP Code

Social Security Number*

Date of Birth*

Gender*

Male

Female

Grade Entering*

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

Racial Identity

White

Black

Asian

Native/Pacific Islander

Indian/Alaska Native

Are You Hispanic/Latino

Yes

Parent/Guardian Information

Parent/Guardian Name*

First Last

Phone #1*

Phone #2

Email*

Academic & Home Life Experience

Previous school attended

Please request transfer records to be sent to Leadership Preparatory Charter School

Reason for transfer

Does the student receive any special education services (IEP, speech, audio behavior)?

Yes

At home, does your scholar have access to the following items?*

Computer

Internet

Does the scholar have any siblings attending LPCS?*

Yes

List sibling names*

Parent/Guardian Contact Information

Scholar Name

First Last

Grade

School Year:
2020-2021

Primary Contact

Parent / Guardian Name

First Last

Relationship*

Primary Phone Number*

Secondary Phone Number

Email Address*

Does scholar live with primary contact?*

Yes

Address (if different from scholars)

Secondary Contact

Parent / Guardian Name

First Last

Relationship

Primary Phone Number

Secondary Phone Number

Email Address

Does scholar live with primary contact?*

Yes

Address (if different from scholars)

Request for Permanent Records | 2021-2022 School Year

Name of Scholar*

First Last

has enrolled in Leadership Preparatory Charter School and the student’s first day will be August 1, 2022.

Please send the following information to:

Leadership Preparatory Charter School

4190 Elliston Road

Memphis, TN 38111

Phone: (901) 512-4495

Fax: 901-512-6852

Email: outreach@leadmemphis.org

Information

Cumulative Records

Physician’s Record

Dental Record

Special Education (IEP/ETR)

Copy of Students Data Form

Expulsion/Suspension Documents

Grade Card

Immunization Record

Birth Certificate

Name of School Child Last Attended*

School District*

School Address*

Street Address City Zip Code

Last Grade Attended*

PreK

In accordance with the Family Educational Rights and Privacy Act dated June 17, 1976, parental permission is no longer required when records are requested by authorized school personnel.

Signature of Parent/Guardian*

Date*

Thank You,

Leadership Preparatory Charter School

Student Health Information

Your child’s learning depends upon good health. Please complete this form with information you are comfortable sharing. Health conditions currently affecting your child are of greatest significance

Student Name*

First Last

Gender*

Male

Female

Date of Birth*

Grade*

Allergies?*

Yes

Please list allergies

Has the allergy required emergency care in the past?*

Yes

Yes, please explain

Does the child use emergency medication for an allergy?*

Yes

Yes, please explain

Please indicate if there are health concerns that pertain to the student*

None

Asthma

Skeletal Problem

Frequent Infections

Anxiety

Bladder

Breathing Condition

Sleeping Disorder

Diabetes

Glasses/Contacts

Ear Infection

Bi-polar

Required Diapering

Dental Issue

Skin Rashes/Lesions

Epilepsy/Seizures

Lazy Eye

Hearing Aid

OCD

Bowel Condition

Neurological Problem

Eating Disorder

Heart Condition

Crossed Eyes

ADD/ADHD

ODD

Special Diet

Nosebleeds

Surgery

(check all that apply)

Please explain in more detail any items that you have circled above.

Does your child require special health care or need to be restricted during specific activities?*

Other health information or concerns:

Your child’s health and education are extremely important to us. The above information will be used to facilitate your child’s learning. Informing and educating staff about the needs of your child will help promote his/her well-being. Confidentiality will be maintained and the information will be shared with those responsible for the sole purpose of meeting the care and custody of the child’s medical needs.

Signature of Parent/ Guardian:

Date*

Student Emergency Care Information

Dear Parent/Guardian,

Thank you for completing your child’s Student Health Information form. If your child has a medical condition that requires attention/assistance, we ask that you:

Complete and sign the attached Emergency Care Plan and the “Parent/Guardian” section of the Medication Administration Form.
Have your child’s health care provider complete and sign the “Health Care Provider” section of the attached Medication Administration Form.
Return the signed forms to the Leadership Preparatory Charter School Office.

Please note:

No medication will be administered or self-administered at school without a Medication Form completed and signed by your child’s health care provider and you.
One Medication Administration form is needed for each medication.
The medication must be delivered to the school in a pharmacy-labeled container with clear instructions.
Medical information will be shared with school staff on a need-to-know basis to ensure the health and safety of your child.

If you feel that your child’s medical condition does NOT need assistance at school, please sign below and return this letter to the school.

My child does NOT need Services.

Student Name*

First Last

Date of Birth*

Parent / Guardian Name*

First Last

Parent/Guardian Signature*

Date*

Emergency Care Plan

The purpose of this document is to enable parents and guardians to authorize the provision of the emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

Student Name*

First Last

Gender*

Male

Female

Date of Birth*

Adults Who Have Permission to Pick Up Your Child

Name*

Relationship to Student*

Phone Number*

Name

Relationship to Student

Phone Number

Adults Who DO NOT Have Permission to Pick Up Your Child

Name

Relationship to Student

Phone Number

Name

Relationship to Student

Phone Number

Adult/Entities Who May Grant Consent for My Child to Receive Medical Treatment

Name*

Relationship to Student*

Phone Number*

Family Doctor Name*

Location*

Phone Number*

In the event reasonable attempts to contact me (parent/guardian) have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or, in the event the designated preferred practitioner is not available, by any licensed physician or dentist, and (2) the transfer of the child to any hospital reasonable accessible. This authorization does not cover major surgery

Signature of Parent/Guardian

Date

I do NOT give permission for emergency medical treatment to my child. In the event of illness or injury requiring emergency treatment, I would like for the school authorities to take the following actions:

Signature of Parent/Guardian

Date

Photo/Video/ Media Release Form

Dear Parent/ Guardian,

On occasion, representatives from the media wish photograph, videotape, and/or interview students in connection with school programs or events. Educating the public is one of our objectives, and the entire community benefits from knowing about the needs and abilities of our students and about the programs we offer to children and families. In order to release student photos, video footage, comments, and/or post on our social media page or website, we need written permission. To give your consent, please complete the form below.

Parent / Guardian Name*

First Last

, parent/guardian of

Student Name*

First Last

give permission for my child to be photographed, videotaped, and/or interviewed by representatives from the media for the purpose of publicizing educational programs. I authorize Leadership Preparatory Charter School or anyone authorized by the Leadership Preparatory Board of Directors the use and reproduction of any and all photographs/videotapes taken of my child, without compensation to me/my child. All of the photographs/video recordings shall be the property, solely and completely, of Leadership Preparatory Charter School. I waive any right to inspect or approve the finished photographs/videotapes, sound track, script, or printed manner that may be used in conjunction with them.

Signature of Parent/Guardian*

Date

Leadership Prep Scholar Seat Acceptance Form

As a Leadership Prep Scholar, I pledge to:

Attend school every day, on time, without exceptions or excuses
Arrive “prepped-up”, prepared, and ready to learn
Attend all required after-school tutoring, Saturday Opportunity Days, and/or Summer Academy
Complete all my homework, read 30 minutes every night, and prepare for all tests
Always strive to show iLEAD values (Integrity, Leadership, Enthusiasm, and Determination
Use my gift, talents and dedication to work hard and prepare myself for college and beyond

As a Leadership Family, we pledge to:

Attend all family conference and major school events
Ensure students are in full uniform every day
Ensure reliable transportation for your child for school, and other required events
Review and sign any academic or behavioral reports
Engage in advocacy efforts to create great public schools for every student in Tennessee

By signing this form, you are agreeing to enroll at Leadership Prep, abide by the pledges above to the best of your ability, and agree to all items found in our Student Handbook, which will be provided to you at the start of the new school year.

Scholar Name*

First Last

Scholar Signature*

Parent/Guardian Signature*

Date

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