Waivers Waivers & Immunization Record Step 1 of 6 - Physical Education 16% IMMUNIZATION RECORDPlease upload the student's most recent immunization/vaccination record(you may skip to the next step if you do not have immunization forms at this time) TRANSPORTATION WAIVERI, the parent/guardian grant my child permission to participate in regular Excelsior Academy field trips, lunches, and require transportation by Excelsior Academy Staff from the school facility at, Outreach Center of West Houston (725 Bateswood Dr, Houston, 77079) to specific field trip events designated by Excelsior staff. I grant permission to allow fellow Excelsior parents to transport my child in the event that Excelsior staff cannot transport students in their personal vehicles. Excelsior parents will be informed of fellow chaperones via email or SMS. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“student”). I agree on behalf of myself, my child named herein to hold harmless and defend Excelsior Academy, its officers, directors, employees, contractors, and agents from any claim arising from or in connection with my child attending these events or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Excelsior Academy, its representative(s) associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence Excelsior employees and contractors. The term of this Agreement is vaild from Trial Day and/or first day of Excelsior enrollment and until the end of school year, or until withdrawal from the School, whichever is earlier. Individual(s) in charge: Excelsior Academy Staff/Teachers. Mode of transportation to and from event: private vehicles (sedan) or mini-van Parent/Guardian Name* First Last Email* Date* Student Name* First Last Student Date of Birth* Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Parent/Guardian Electronic Signature (Transportation)* PHYSICAL EDUCATION WAIVER & RELEASE OF LIABILITYI understand the risk of injury from participation in any of the physical education activities offered by Excelsior Academy is significant and dangerous, including the possibility of serious and permanent bodily injury. I confirm that my child is physically able to participate in such activities. By electronically signing, I agree to the Excelsior Academy Release of Liability & Waiver Form, I am voluntarily and knowingly waiving any and all claims I have or come to believe I have in connection with my child’s participation in physical education activities offered by Excelsior Academy. I further release Excelsior Academy and its employees, volunteers, and Board members from any and all liability for their acts in connection with the same. First Aid and Emergency Medical Treatment: I acknowledge there may be occasions during which my child is injured and medical treatment may be deemed necessary. I do hereby give my permission for qualified personnel to provide my child with appropriate medical treatment, especially in an emergency situation. The term of this Agreement is vaild from Trial Day and/or first day of Excelsior enrollment and until the end of school year, or until withdrawal from the School, whichever is earlier. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor (“student”). I agree on behalf of myself, my child named herein to hold harmless and defend Excelsior Academy, its officers, directors, employees, contractors, and agents from any claim arising from or in connection with my child attending these events or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate Excelsior Academy, its representative(s) associated with the event for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence Excelsior employees and contractors. Parent/Guardian Name:* First Last Student Name:* First Last Parent/Guardian Electronic Signature (Physical Education)*Date* PHOTO/IMAGE CONSENT - CHOOSE 1 OPTION A, B, C, or DCHOOSE OPTION A, B, C, DI acknowledge by my signature on this permission that my child's photo/image and personally identifiable information to be published on the school's web site, for distribution to prospective Excelsior Academy parents via email, or for demonstrations to other schools in the Excelsior Academy network. Pursuant to law, we will not release any personally identifiable information without prior written consent from you as the parent or guardian. Personally identifiable information includes student names or nicknames. If you, as the parent or guardian, wish to withdraw from this agreement, you may do so at any time in writing by sending an electronic letter to the principal and rescission will take effect upon receipt by the school. The school website address is: www.excelsiorhouston.com. The term of this Agreement is vaild from Trial Day and/or first day of Excelsior enrollment and until the end of school year, or until withdrawal from the School, whichever is earlier. PHOTO/IMAGE CONSENT - CHOOSE 1 OPTION A, B, C, or DOPTION A: I want my child excluded from all photos. I do not want my child's photo taken for any reason. This would exclude your student from classroom photos and field trip photos.OPTION B: I grant permission for this student's photo/image to be shared WITHOUT personal identifiers. This means that the school can publish photos and images of the student on the school's website, distribute them to prospective Excelsior parents, or distribute them to other schools or educational organizations WITHOUT personal identifiers. Personal identifiers can include the student's name and more.OPTION C: I grant permission for this student's photo/image to be shared WITH personal identifiers. This means that the school can publish photos and images of the student on the school's website, distribute them to prospective Excelsior parents, or distribute them to other schools or educational organizations WITH personal identifiers. Personal identifiers can include the students name and more.OPTION D: I grant permission for photos and images to be taken of this student, but ONLY for internal distribution between teachers, parents and faculty. This would include class pictures, pictures taken on field trips and other class activities.Parent/Guardian Name:* First Last Student Name:* First Last Parent/Guardian Electronic Signature (Photography)* TECHNOLOGY USE AGREEMENTThis Laptop and Tablet Use Agreement is between EXCELSIOR ACADEMY and the Parent/Student: EXCELSIOR ACADEMY may assign your student with a designated Laptop and use of a Tablet in the classroom. The receipt of this Equipment are acknowledged since the first date of the student’s enrollment date and the Agreement is as follows: 1. Equipment. EXCELSIOR ACADEMY assigns to Student the use of Labtop equipments and accessories: Estimate retail value of laptop: $500-600. Estimate value of tablet: $50 2. Period of Possession. The term of this Agreement is vaild from Trial Day and/or first day of Excelsior enrollment and until the end of school year, or until withdrawal from the School, whichever is earlier. The Student or EXCELSIOR ACADEMY may terminate this agreement at any time by written notice. 3. Altering or Defacing Equipment. Student will not alter, disfigure, or cover up any numbering, lettering, or insignia displayed on the Equipment. Student will not alter or remove software or add unauthorized/unlicensed applications. 4. Maintenance and Repair. EXCELSIOR ACADEMY agrees to keep the Equipment in good repair and operating condition. Gross negligence by Student will not be tolerated. It is the Student’s responsibility to provide reasonable care. Parents/Guardians are responsible for reasonable cost of repair or replacement of deliberately damaged devices. 5. Use. Student agrees that the Equipment will not be subjected to unnecessarily rough usage, that it will be used in accordance with its design and EXCELSIOR ACADEMY policies & procedures, and Handbook. 6. Loss or Damage. A Student who acts in bad faith to damage, steal, misplace or purposely not return the Laptop/Tablet and/or accessories will be liable and/or the Parent/Guardian of the student will be liable to EXCELSIOR ACADEMY for the replacement cost of the Equipment and/or accessories as of the date of loss. If the device is lost on campus, then the student must immediately report it to the campus administrator. 7. Disclaimer. While EXCELSIOR ACADEMY uses technology protection measures to limit access to material considered harmful or inappropriate to students, it may not be possible for the school to absolutely prevent such access. 8. Responsible Use. Student should use electronic devices appropriately, refrain from browsing non-school related sites, and follow the teacher's instructions. 9. Location and Ownership. The Laptop/tablet will remain on Excelsior property at all times. The Laptop is and will remain for the term of this use agreement school property. I hereby agree that I have reviewed the terms of this Agreement and the information provided and agree to abide by them.Parent/Guardian Name* First Last Student Name* First Last Parent Electronic Signature (Technology)* HANDBOOK ACKNOWLEDGEMENTPlease carefully read the Excelsior Academy Parent/Students Handbook. This Handbook applies to students entering in the current school year. Parents will be notified in advance regarding any major changes to the Handbook.* I (We) have reviewed the Excelsior Academy Parent/Guardian/Student Handbook with my child(ren) enrolled at Excelsior Academy, and I/we agree to abide by the policies and procedures set forth. The Parent/Student Handbook can be accessed at the following link: https://excelsiorhouston.com/handbook/ Student Name First Last Parent/Guardian Electronic Signature (Handbook)*IEP and 504Upload IEP and/or 504Upload Formal Testing EvaluationsStudent RecordsStudent Birth CertificateStudent Last Report Card (only transfering student)Parent Driver LicenseUntitledFirst ChoiceSecond ChoiceThird Choice
