Registration

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Student & Parent Information

Student First Name Student Last Name Date of Birth Grade Level GPA (optional) School Name Home Address

Parent/Guardian First Name Parent/Guardian Last Name Parent/Guardian Phone Parent/Guardian Email

Safety Information

Emergency contact is required. Physician details are only needed if you listed allergies, conditions, or medications.

Emergency Contact

First Name Last Name Contact Number Alternate Contact (optional)

Medical Information

Allergies (optional) Medical Conditions (optional) Medications (optional)

Physician First Name Physician Last Name Physician Contact Number

Programs & Payment

Year

Semester

Payment Preference

Policies & Agreements

Expand each policy to review the details, then sign once at the bottom.

Parental Consent

I give permission for my child to attend enrichment classes at Lexington Science Academy. I understand precautions will be taken for my child's safety and that staff may secure medical treatment in an emergency if I cannot be reached.

Enrollment Agreement

I agree that inappropriate behavior (including cell phone use during class, distracting others, profanity, or harassment) may result in unenrollment with a prorated refund for remaining classes.

Absence & Withdrawal Policy

Tuition is due two weeks before classes begin. Withdrawals require one month's written notice. Missed classes may be eligible for a makeup at teacher discretion, but no credit or refund is provided for missed lessons.

Safety & Liability

I agree to comply with LSA rules and accept responsibility for facility damage caused by my child. I will not hold LSA, its directors, teachers, or staff liable for accidents, injury, illness, or property damage.

Communication Preferences

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I have read and agree to all policies above Parent/Guardian Initials Date