2019-2020 Family and Student Records

***The first section of this form, titled “STUDENT PROFILE - Student Insights” requires input from your student. The following sections are for parent(s)/ guardian(s) to complete.

Student's Name *
Student's Name
Student's Date of Birth *
Student's Date of Birth
STUDENT PROFILE - Student insights
This section is meant to be completed by the student. If necessary or appropriate, the parent/guardian may read and/or type in the information for the student
Student Agreements *
An Agile Learning Center is a place where students of all ages are allowed to direct and schedule their learning and activities. Students also participate in shaping the cultural norms of the school environment. Being an Agile learner comes with certain responsibilities. I understand that I am expected to:
STUDENT PROFILE - Parent/ guardian insights
This section is intended to be completed by the parent(s) and/or guardian(s) of the student
FAMILY PROFILE
If we mutually agree on the enrollment of your family into the Heartwood community, the following Parent/ Guardian Family Profile information section may appear in our Family Directory as an opportunity for other families in the community to get to know a bit about you and your family. You will be asked at the end of the family profile section if you consent or if you have any special stipulations.
Parent/Guardian #1 *
Parent/Guardian #1
Parent/Guardian #1 Phone Number *
Parent/Guardian #1 Phone Number
Parent/Guardian #1 Address *
Parent/Guardian #1 Address
Parent/Guardian #2
Parent/Guardian #2
If applicable
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Phone Number
Parent/Guardian #2 Address
Parent/Guardian #2 Address
Parent/Guardian #3
Parent/Guardian #3
If applicable
Parent/Guardian #3 Phone Number
Parent/Guardian #3 Phone Number
Parent/Guardian #3 Address
Parent/Guardian #3 Address
We need this information to enroll student's yearly with the school superintendent's office.
Do you consent to items from your Family Profile being used in the parent directory? *
SCHOOL AND COMMUNITY
Agreement to Educational Philosophy *
Heartwood ALC provides a learning environment for students to develop self-direction, self-motivation, and self-knowledge. Heartwood ALC does not make any guarantees about student's academic or developmental outcomes. Nor does the school require students to attend specific classes or produce specific work. The facilitators will support student's requests for learning but do not direct learning activities according to any larger curriculum. For the smooth and safe operation of the school, the facilitators may make certain activities mandatory. Beyond these select activities, the choices are up to each student.
Community Involvement *
Heartwood is a community that requires participation. Parent/Guardians are expected to complete at least 30 hours of volunteer time throughout the school year.
EMERGENCY CONTACT INFORMATION
Emergency Contact #1 *
Emergency Contact #1
In addition to the named parent/guardian(s) above
Emergency Contact #1 Phone Number *
Emergency Contact #1 Phone Number
Emergency Contact #2 *
Emergency Contact #2
In addition to the named parent/guardian(s) above
Emergency Contact #2 Phone Number *
Emergency Contact #2 Phone Number
HEALTH AND DEVELOPMENT INFORMATION
Physician's Name *
Physician's Name
Physician/Clinic Phone Number *
Physician/Clinic Phone Number
Physician/Clinic Address *
Physician/Clinic Address
Please list any dietary restrictions your child may have:
Please list any allergies your child may have:
Please list any health issues your child may have (frequent headaches, sinus infections, earaches, etc.):
Please list any psychological diagnoses you feel our staff should know (for both safety and to best meet your child’s needs):
Please list any developmental issues or needs you feel our staff should know (for both safety and to best meet your child’s needs):
Please list any phobias or heightened sensitivities your child may experience:
Has your child experienced any major life events in the past year (I.e., birth of a sibling, death of a family member, divorce, moving, etc.)?
Please list any other health or development items you feel our staff should know:
HEALTH CONDITION FORMS
If the answer is 'yes' to any of the following questions, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
Does your child need to take any prescription or over-the-counter medication during the school day? *
If the answer is 'yes' to this question, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
Does your child have any debilitating or life threatening allergies? *
If the answer is 'yes' to this question, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
Does your child need an Individual Health Care Plan? *
If the answer is 'yes' to any of the following questions, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
Does your child have asthma? *
If the answer is 'yes' to this question, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
Does your child have diabetes? *
If the answer is 'yes' to this question, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
Does your child have a seizure disorder? *
If the answer is 'yes' to this question, please contact admin@heartwoodalc.org as soon as possible to discuss proper medical and/or legal protocol.
PERMISSIONS - Water Play
PERMISSIONS - Image Use
I give permission for my child to be included in any image recording connected with the school’s program which is purely intended for internal purposes. This might include posting to the internal-facing Facebook account, internal-facing Instagram account or ALC blogs that are intended to be shared with those inside the Heartwood ALC community. Please be aware it is possible that these forms of media may also be posted on the Internet at-large without the permission of Heartwood ALC.
I give permission for my child to be included in any image recording connected with the school’s program, specifically external-facing media. This might include postings to the external-facing Facebook account, external-facing Instagram account or ALC blogs that are intended to be shared with the ALC community worldwide. I understand that those images may be used as documentation on the school’s website, newsletter or marketing materials.