Complete Student Registration Online Form: Complete Student Registration "*" indicates required fields Step 1 of 11 9% Student InformationStudent Registration* New Student Registration Returning Student Registration Name* First Last Middle Name (optional) Nickname (optional) Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemalePrefer Not to AnswerEthnicity* Student CellStudent Email* Address* Street Address City ZIP Code Additional InformationProbation* Yes No Diversion* Yes No Truancy* Yes No Social Worker* Yes No Counselor* Yes No Therapist* Yes No Psychologist* Yes No Physician* Yes No Probation Officer Name Diversion Officer Name Truancy Officer Name Social Worker Name Counselor Name Therapist Name Psychologist Name Physician Name Tylonel/Ibuprofen allowed* Yes No Antacid/Cough drop allowed* Yes No Physical limitations/medical conditionsList all RXs and dosesRXDose Add RemoveEligible for free/reduced lunch* Yes No Does student have access to an electronic device* Computer Tablet Other Does student have internet access to complete coursework?* Yes No T-Shirt Size* If your student is eligible, would they like to participate in the home school graduation ceremony?* Yes No Mother / Female Guardian InformationName* First Last Home Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell phoneHome phoneWork phoneEmail Marital StatusSingleMarriedDivorcedWidowedCustody* Yes No Lives with* Yes No Father / Male Guardian InformationName* First Last Home Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell phoneHome phoneWork phoneEmail Marital StatusSingleMarriedDivorcedWidowedCustody* Yes No Lives with* Yes No Emergency ContactsEMERGENCY CONTACTS should consist of trusted individuals that we can contact if you are not reachable and/or can pick up the student if sick or suspended:Emergency Contacts*NamePhoneRelationship Add Remove Student Handbook & Rights/Responsibilities AcknowledgementPREMIER ACADEMY REQUIRES ALL STUDENTS AND PARENTS TO ACKNOWLEDGE, IN WRITING, THAT THEY HAVE RECEIVED A COPY OF THE STUDENT HANDBOOK CONTAINING SCHOOL POLICIES AND PROCEDURES and understand it is their responsibility to read its contents and to comply with the rules explained in the handbook. We acknowledge that, if we do not understand any provisions of this handbook, it is our responsibility to seek out clarification from an administrator. Chronically poor attendance may result in the following actions: student/parent conferences, home visits, revocation of driving privileges, truancy interventions, court referral and/or removal from Premier. Students who do not maintain 90% or higher attendance may forfeit their ability to participate in activities such as: home school athletics, school dances, or home school graduation ceremony. Cell phone usage during the school day is prohibited. Students who choose to bring their cell phone to school must turn off the device and hand it to staff upon entry to the building for secure storage. Ear buds must be turned in and will be stored with their phone. All over the ear headphones will be confiscated; phones and ear buds will be returned at dismissal. All students enrolled at Premier Academy must consent to a search (including, but not limited to pat down) of their person and inspection of belongings before they enter the facility and upon every reentry. Ball caps, over the ear headphones, and any backpack that isn’t Premier issued will not be allowed in the building. Any item deemed as contraband will be confiscated and not returned. Illegal contraband items may result in the immediate involvement of local law enforcement and removal from Premier. Premier Academy is a Drug-Free School and as such prohibits the possession, sale and arriving under the influence or use of drugs, alcohol, tobacco or any intoxicating substance while on school property. Notification of bullying (as defined by the Premier Academy Student Handbook and IL School Law 12:355) will not be tolerated and disciplinary actions will be taken on a case by case basis. Premier Academy maintains temporary files (semester grade reports, attendance, and general behavior records) on each student for 5 years. For all temporary file requests from Premier Academy’s records, 72 hours notice will be required to obtain any documents/information. STUDENT RIGHTS: To attend school To appropriately express their opinion one-on-one with the appropriate Premier Academy staff member To expect that the school be a safe place for all students to gain an education To not have their rights infringed upon by another student STUDENT RESPONSIBILITIES: Students are to treat everyone associated with Premier Academy (fellow students, teachers, support staff, administration, guests, etc.) with dignity and respect. Student behavior that interferes with other students’ learning opportunities to learn, teachers’ opportunity to teach, or others’ rights to function in the building will not be tolerated. Those attending Premier Academy are expected to act like responsible students at all times. Premier staff are in charge of the program. As such, students are expected to follow their directives. Those who fail to do so will be considered insubordinate and subject to disciplinary action. If a student questions a staff member’s decision, the student should do as the staff member directs and then see an administrator at an appropriate time to discuss concerns. Students are expected to pick up after themselves and help maintain a clean and safe school environment. This applies to all areas of the school: hallways, classrooms, restrooms, offices, gymnasium, and outside areas. PARENT RESPONSIBILITIES: To actively participate in your student’s education To ensure student attendance; students are required to maintain a 90% attendance rate (2 or less absences per month) To monitor student progress To maintain most current contact and emergency information and ensure student’s immediate pick up if sick, disruptive or suspended [dearpdf id="9629" ][/dearpdf]You, the parent, acknowledge that you have been fully informed of all Premier Academy policies and agree to all terms listed within the Student Handbook and Parent Responsibilities.* Yes Parent Name* First Last Parent Signature*Date Signed* MM slash DD slash YYYY You, the student, acknowledge that you have been fully informed of all Premier Academy policies and agree to all terms listed within the Student Handbook and Student Rights & Responsibilities.* Yes Student Name* First Last Student Signature*Date Signed* MM slash DD slash YYYY Address* Street Address City ZIP Code Student Name* First Last Parent Name* First Last Parent Signature*Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address City ZIP Code Support Services Parental Informed ConsentPremier Academy, along with various outside providers, offers individual and group counseling services to students who are enrolled. We are hoping to work with your student during this school year. When your student participates in counseling, he or she will have the opportunity to explore personal strengths and gain knowledge about different problem solving techniques. All information from the counseling relationship will be confidential, within reason. Any concerns regarding these services can be directed to Becky Peterson at 815-416-0377 ext. 1200. Confidentiality and Limits of Confidentiality Trust and honesty are critical to the development of all counseling relationships. For this reason, we place high value on the confidentiality of information shared in sessions. You should be aware that legal requirements specify certain conditions in which it may be necessary for the school or counselor to discuss information about the student with other professionals. If you have any questions about these limitations, please ask the Premier Case Manager. Such situations include but are not limited to: Concern that your child may harm him/herself or others. Reported or suspected abuse victimization: Physical, sexual, mental, medical, neglect. Reported or suspected abuse perpetration of: Children, elderly, or disabled persons. Court mandated action. It is also important to note that on some occasions it will be in the best interest of your child that the counselor discusses information with other support staff both at Premier Academy and with your child’s home school. I agree that I have read the above information and that the nature of the sessions were explained. I hereby consent to have the student listed on this form counseled at Premier Academy. Student Name* First Last Student Signature*Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent Name* First Last Parent Signature*Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Release of Liability for Community ServiceI, on behalf of myself and my next of kin, heirs and representatives, release from all liability and promise not to sue Premier Academy, a Program of the Grundy/Kendall Regional Office of Education and their employees, officers, directors, volunteers and agents from any and all claims, including claims of Premier Academy’s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because of my participation in Community Service, including travel to, from and during the Community Service. I am voluntarily participating in Community Service. I am aware of the risks associated with traveling to/from and participating in Community Service, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, or negligence; conditions related to travel; or the condition of the Community Service location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in Community Service, including travel to, from and during Community Service. I agree to hold the Premier Academy harmless from any and all claims, including attorney’s fees or damage to my personal property that may occur as a result of my participation in Community Service, including travel to, from and during Community Service. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me.Participant Name* First Last Participant Signature*Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent Name* First Last Parent Signature*Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hours mandated by:* Home SchoolProbation/Diversion Officer:* Community Services Hours Needed:* *Student does not need to be mandated to participate in community service and may choose to help Premier staff with activities and events at our facility. However, student cannot participate without a completed waiver. Transportation FormStudent Name* First Last Student Phone*Parent(s) / Emergency Contact*NamePhone Add RemoveStudent Transportation* Bus Rider Driver Walker (or bring driven to school daily) Bus Rider InfoBussing Start Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home School* Address (Pick up & Drop off)* Street Address City ZIP Code *Student is expected to arrive and leave school on the bus, unless the bus company and main office are notified of other arrangements.Driver InfoVehicle(s)*YearMakeModelColorPlate # Add RemoveWalker InfoTransportation in case of emergency/inclement weather:* Fees Intake FormI have been informed of the fees and agree to:* Enrollment Fee: 1 payment of $50 due upon enrollment McKinney-Vento Act/Free & Reduced Lunch: fees waived Yes Please make checks payable to: Grundy/Kendall ROEStudent Name* First Last Parent Signature*Signature Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Students will be issued one pair of headphones for the current school year, and the headphones must remain in the building at all times. If lost or broken, there will be a $10 replacement fee per pair. PhoneThis field is for validation purposes and should be left unchanged.
Edgenuity/Imagine Learning
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