Enrollment Application

Kindergarten through 8th Grade

Thank you for your interest in Crescent Academy. In order for your child’s application to be processed, we are required to have
the following documents returned to Crescent Academy Enrollment Office. Your child’s enrollment packet will be considered
incomplete until we have received all of the necessary documents.

ENROLLMENT CHECKLIST
REQUIRED DOCUMENTS

_____ Birth Certificate (original)

_____ Vision Test –Kindergarten Only
_____ Immunization Record/Health Appraisal
Note: Shot records are required for all new students, as well as Students currently
enrolled/ enrolling in the 7Th grade.

_____ Copy of Last Report Card Issued

_____ Standardized Test…i.e..MSTEP, NWEA
(Grades 3-High School – all subjects)
_____ Photocopy of Parent I.D./License

_____ Student Essay -grades 6 thru 8th

Topic: Who is your hero? Attach a separate sheet and submit with application

OFFICE USE ONLY:

Application Receipt Date: ________

STUDENT NAME: _______________________________________
Application taken by: ___________

Campus______________________
BIRTH DATE: _______________
Siblings Attending Crescent:

GRADE: ____________
 Kindergarten through 8th

Enrollment Application
[ ] New Student [ ] Returning Student
Grade Applying for 2019-20: ___________________
STUDENT DEMOGRAPHIC INFORMATION
Student’s Name:
Last Name First Name Middle Initial
Gender:
Student’s Date of Birth: ____/____/_______  Male
(Provide Birth Certificate)
 Female
Home Language Is your child What is the race of the child? (Choose one or more boxes)
Hispanic/Latino?  American Indian or Alaskan Native
What is the primary (Choose only one)  Asian
language spoken in  Yes  Black or African-American
your home?  No  Native Hawaiian or Pacific Islander
 English  White
 Other:_________  Other _____________________
_____________

MEDICAL HISTORY
List severe allergies:
(i.e., peanut allergy,etc. )
List medical concerns
which require a medical
action plan: (Chronic health
concerns such as diabetes,
asthma, epilepsy, etc.)
List medications/
treatments:
Where is medication [ ]Home [ ]School [ ]Both If medication is administered at school,
administered? an “Authorization to Administer
Medication form must be completed by
parent or doctor. Medication will not be
dispensed withot completed form.

Are there any family members in the United States Military? [ ] Yes [ ] No

If yes, who is the person:__________________________________ Relationship to student:______________

How did you hear about Crescent Academy?
[ ] Relative or Friend whose child attends Crescent [ ] Special Event [ ] Walk In
[ ] Advertisement/Social Media [ ] Website
If no services apply below, check box: [ ] No Services
_____________Check here if Special Education Services are currently provided … Submit copy of IEP
SPECIAL SERVICES (Please check all that apply) Attach copy recent IEP / MET Evaluation Reports

Support Services: Special Education: Service Delivery:

 504 Plan: Diability _________________
 Speech Therapy
 Occupational Therapy
 Physical Therapy
 Social Work
 Assistive Technology _________
 English as a Second Language
 Title IA/31a Services
 Response to Intervention (RTI)
 Other: __________________
 Specific Learning Disability  Self-contained classroom
 Emotional Impairement  Resource Room pull-out
 Cognitive Impairement  Resource Room push-in
 Physical Impairement  Co-taught courses
 Other Health Impairement  TC support only
 Autism Spectrum Disorder  Date of last IEP: ________
 Visual Impairement  Date of last REED: _______
 Hearing Impairement
 Early Childhood
Developmental Delay
 Speech and Language
Impairement
 Severe Multiple Impairement
 Traumatic Brain Injury
 Other: __________________

I have reviewed the above services: Please Initial ____________

______________________________________________________________________________

DISCIPLINE HISTORY
 Has your child ever received an in-school detention?  Yes  No
 If yes, how many times? ______ When did the detention occur? _____________________________________

 Has your child ever received a suspension from school?  Yes  No
 If yes, how many times? ______ When did the suspension occur? ____________________________________

 Has your child ever been expelled from school?  Yes  No
______Initial l Parent ROBO Call Notifications come via text messaging and/or telephone calls
(This form of communication is generated to Crescent Academy District parent/guardians for informational
purposes.) Examples of use: Reminder of schoolwide events, school closings etc.
PARENT/GUARDIAN INFORMATION
Name: Relationship:

Parent/Guardian #1 Street Address:

(Address where
City: State: Zip Code:
student lives) Home Phone:
Day Number/Cell Phone:
Work Phone: Email:
Name: Relationship:

Street Address:
Parent/Guardian #2
City: State: Zip Code:

Day Number/Cell Phone:

Work Phone: Email:

EMERGENCY CONTACT INFORMATION

Name: Relationship:
Emergency Contact #1 Day Phone #:

Name: Relationship:
Emergency Contact #2 Day Phone #:

Name: Relationship:
Emergency Contact #3 Day Phone #:

Legally, do not release my child to: ____________________________________________.

The Academy will not comply with your request until receipt of Personal Protection Order
and/or Custody Papers.
SIBLINGS (Please list all siblings who are also applying for enrollment at the Academy. Information in this section is to ensure
sibling status if one of your children is accepted. Each child applying must complete a separate Student Enrollment Application.)
Last Name First Name Class

• I understand that by completing and signing this form that my child will be considered for enrollment
at the Academy. I further understand that this process does not automatically guarantee enrollment
in the Academy, and that my child’s name may be placed in a lottery for enrollment purposes.
• I affirm that all the information provided is complete and accurate to the best of my knowledge:

X Parent/Guardian Signature Required Date

______________________________________________ ________________________
 Internet Acceptable Use Agreement

Internet services are available to all students for the purposes of instruction, curriculum support, and communication. Email,
network, or internet access is to be used ONLY for these purposes.

As the parent or legal guardian of students enrolled in Crescent, I grant permission for my child to access the Internet. I
understand that it is impossible for the Academy to restrict access to all controversial material and release the Academy from
any and all claims that may result from my child’s use of the Internet or internal computer network. I accept full responsibility
for supervision of my child when accessing Internet resources provided by the Academy outside the school premises.

PLEASE READ RULES/CONDITIONS FOR INTERNET USE:

This agreement outlines the rules for responsible use of the Internet at the Academy. Please read this with your child. In order for your child to access the
Internet, we require that this agreement be signed and returned to school.
✓ The Academy will provide each student with training in the proper use of the Internet.
✓ Each student is responsible for proper behavior while on the Internet. The same general school rules for behavior and communication apply to
Internet usage.
✓ The use of the Internet is a privilege, which may be withheld if the student is irresponsible, or acts inappropriately.
✓ The school has a right to monitor all activity, e-mail correspondence, and material transmitted or received by students on school computers.
✓ Students are not permitted to transmit or publish any defamatory, abusive, profane, threatening, or illegal material.
Accessing, uploading. downloading, distributing or transmitting pornographic, obscene, sexually explicit, or threatening material or other
materials harmful to minors.
✓ Students must respect all copyright laws that protect software owners, artists, and writers.
✓ Security is a high priority at the Academy. Using someone else’s logon id or password is prohibited. Trespassing in another’s files without
permission is prohibited.
✓ The Academy will take appropriate measures to protect students from accessing inappropriate information and from receiving or engaging in
inappropriate communications. However, due to the unregulated and ever changing nature of the Internet, we assume no liability for any
damages a user may incur as a result of Internet access.

Unacceptable use includes but is not limited to:

Behaviors in violation of Crescent Policy, state statues ,or federal laws

Student Name______________________________________

I have reviewed this agreement with my child, understand, and agree with the terms and conditions as stated. I understand that the school’s
computing resources are for educational purposes only.

Parent Signature
Student’s Name: __________________________________________ Grade: _________
PHOTO CONSENT/DENIAL FORM
In an effort to keep the Academy community up-to-date on school events, the Academy will, on occasion, invite local media representatives into our schools to
photograph special programs and events. Media representatives register at the main office upon their arrival and are always escorted to a designated area from which
they can take photos or video publication. We do not allow media representatives to interview students on school property unless Academy personnel accompany
them.

Academy personnel will also take photos of classroom activities and/or individual students from time to time for either release to the local media or use in Academy
media, official school website or brochures. Identification of students is always limited to name, school, and grade.

Permission to photograph a student either individually or as part of a group is assumed, unless you indicated otherwise below. If you prefer that your student NOT
be shown in any photo or video for media use, school website or Academy publication, please indicate belowy. If you should have any questions regarding the
Academy Community Relations plan, please call us at (248) 423-4581.

 Yes, I give permission for my child’s picture to be used in school publications or school website.
 No, I do not wish to have my child’s picture used in school publications or on the school’s website.

PESTICIDE PRIOR NOTIFICATION:

Pesticide Application Advisory
Pesticide Prior Notification Request
As part of the Academy’s pest management program, pesticides are occasionally applied. You have the right to be informed prior to
any pesticide application made to the school grounds and/or building(s). In certain emergencies, pesticides may be applied
without prior notice, but you will be provided notice following any such application. If you need prior notification, please
complete the information below and submit it to:

_______ No, it is not necessary to be contacted ______Yes

IF YES, COMPLETE THE FOLLOWING:

Please Check One:
 I wish to be notified prior to a scheduled pesticide treatment inside the building.
 I wish to be notified prior to a scheduled pesticide treatment outside the building.
 Both of the above.

TELEPHONE NUMBERS: DAYTIME: _________________ EVENING: _________________

PARENT SIGNATURE REQUIRED:

____________________________________________ Date:________________________
 IMPORTANT MEDICAL ALERT
When required, please obtain medical form from school office

STATE MANDATED CHANGE

IN SCHOOL MEDICATION DISPENSING POLICY

REQUEST FORMS FROM SCHOOL MAIN OFFICE:

✓ Medication Administration Permission Form and Daily Management Plan Form
✓ School Based Care Plan for students with Diabetes Form
✓ School Based Asthma Management Form (to be completed by Doctor)

✓ Any medical condition for which medication is to be administered in school requires the
completion of the form.

The state of Michigan has mandated a change for the method by which medications are dispensed by public school personnel.
As the revised regulation now reads, we must have on file a “Standing PRN Order” from your doctor stating which
medications are prescribed for your child with complete dosage and indication information. This information should appear on
your doctor’s letterhead or prescription pad.

This new regulation also extends to over the counter medications, including all pain relievers and cough drops. Your doctor
must issue an “as needed” order indicating specific dosage for your child’s age and weight. This is especially important if your
child requires a dosage different from package recommendations.

This new policy will be enforced beginning September 2007 and continue throughout the school year. We realize that this
change will be an inconvenience for you, but please understand that it is a statewide requirement. To prepare in advance,
make your requests at your child’s next appointment.
 CRESCENT ACADEMY SCHOOL UNIFORM

Uniforms & Apparel

No exceptions to the uniform dress code –please make logo item purchases from
Crescent Academy to ensure compliance to the uniform dress code

Girl’sUniform for grades K, 1st
White or Light Blue Short/Long Sleeve
Peter Pan Collared Blouse (cotton)
Navy Blue Jumper
Navy Cardigan Sweater
Grey Crescent Academy Logo Fleece
Navy,White or Black socks or tights,
Black Shoes
Girl’s Uniform for grades 2nd -5th
Grey/ NAVY(Pink Limited Edition) Short/Long
Sleeve -Crescent Academy Logo Polo Shirt
Blue Skirt/SKORT ( Must have Box Pleats-NO
STRAIGHT SKIRTS)
Navy Cardigan Sweater
Grey Crescent Academy Logo Fleece
Navy,White, Black Socks or tights, Black Shoes

Girl’s Uniform for grades 6th -8th

Grey/ NAVY Short/ Long Sleeve Crescent Academy Logo Polo Shirt
Royal Blue/ Red /(Anniversary Limited EDITION) Short/ Long Sleeve Crescent Academy Logo
Polo Shirt
Blue Skirt (Must have Box Pleats- NO Straight Skirts)
Navy Cardigan Sweater
Grey Crescent Academy Logo Fleece
Navy, White, Black Socks or tights, Black Shoes

Boy’s Uniform K, 1st Boy’s 2nd -5th

Navy Short/Long Sleeve -
Crescent Academy Logo Polo Shirt
Navy School Pants
Navy Cardigan Sweater (front button)
Grey Crescent Academy Logo Fleece
Black Belt ,Black Shoes, Black Socks
Grey, Navy Short/Long Sleeve -
Crescent Academy Logo Polo Shirt
Navy School Pants
Navy Cardigan Sweater (front button)
Grey Crescent Academy Logo Fleece
Black Belt, Black Shoes, Black Socks

Boy’s Uniform for grades 6th -8th

*Royal Blue/ Red (Anniversary Shirts—Limited Edition)
NAVYor GREYShort/Long Sleeve Crescent Academy Logo Polo Shirt
Navy School Pants
Navy Cardigan Sweater (front button)
Grey Crescent Academy Logo Fleece
Black Belt, Black Shoes, Black Socks
***Elite Students: Special Order POLOs

Physical Education Gym Uniform for Grades K- 8th

Crescent Academy Logo apparel must be purchased from CRESCENT ACADEMY
 Student Residency Questionnaire
This form is intended to address the requirements of the McKinney-Vento Homeless Assistance Act (Title X, Part C of the No Child
Left Behind Act). The question below is to assist in determining if the student meets the eligibility criteria for services provided
under the McKinney-Vento Act.

Please Complete:
Name of student(s): _________________________________________ Date of birth: _____________
________________________________________ Date of birth: _____________
________________________________________ Date of birth: _____________

Parent /Legal Guardian Name: __________________________________________________________________________

Address: ________________________________________________City, Zip_______________________

Phone number: ___________________________ E-mail address: _________________________________

Where does the student stay at night?

Check the appropriate:

_____ in a shelter
_____ in a car
_____ in a motel/hotel
_____ temporarily with more than one family in
a house, mobile home, or apartment (because the
family does not have a place of its own)
_____ student(s) are alone with no adults

____ in another location that is not appropriate

for people (e.g., an abandoned building)
_____ other (in an arrangement that is not fixed,
regular, and adequate and is not described by the
other choices)
_____ at a campsite
_____ placed in temporary foster care

If none of the above apply: Please Check Box : □

Under penalty of perjury under the laws of this state, I declare that the information provided here is true and correct and of my own
personal knowledge and that, if called upon to testify, I would be competent to do so.

Parent/ Legal Guardian's Signature:

_______________________________________________ Date: _____________

.

CRESCENT ACADEMY
Official Request for School Records
Permission for Release and Facsimile Information

Please release the cumulative files, including CA-60, Behavioral and Health Records, Social Work Records,
Psychological Records and/or Special Education Records for the student listed. The student(s) listed enrolled in our
school. Please send all other information which will assist us in placing the student(s) in appropriate classroom setting.

Student Name: _____________________________________ Grade (Applying for): __________

Date of Birth: _____________________________

NAME AND ADDRESS OF LAST SCHOOL ATTENDED:

________________________________________________________________
School Name

_______________________________________ ________________________ ________ ________

School Address City State Zip

School (OFC) #: __________________________School Fax: _____________________________

.
PARENT/ LEGAL GUARDIAN SIGNATURE: ______________________________________________ Date: ________________
(____ Parent or _____ Registrar Signature)

SEND RECORDS TO: □ Iif checked, please fax the following for enrollment
considerations only
ATTN: STUDENT RECORDS
___Last Report Card ____Immunization ____Current IEP
CRESCENT ACADEMY ___ Behavior Record
17570 WEST TWELVE MILE ROAD
SOUTHFIELD, MI 48076 ____________________________________________
248.423.1027 (Fax) 248.423.4581 (OFC) Registrar Signature

The Federal Reg. Vol. 41 No. 188, Sec. 99.31, June 17, 1976 states: “prior consent for disclosure not required… If the disclosure
is…to officials of another school system in which the student seeks or intends to enroll.