Allendale Academy
7208 Amhurst Way
Clearwater, Fl 33764
(727) 531-2481 Office hours Mon-Thu 10am-2pm Est.
e-mail: adacademy@aol.com

STUDENT NAME_____________________________________DATE______________

S.S.#__________________________________PHONE#(_____)___________________

MAILING ADDRESS_____________________________________________________

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BIRTH DATE_______________ BIRTH PLACE__________________AGE_________

SEX__GRADE ENROLLING IN___E-MAIL ADDRESS (Parent's)________________

NAME AND COMPLETE MAILING ADDRESS OF LAST SCHOOL ATTENDED

________________________________________________________________________

________________________________________________________________________

OUR SCHOOL YEAR BEGINS (m/y)_____________ AND ENDS (m/y)_____________

We,___________________________________and______________________________

as parent educators agree to uphold the requirements of Allendale Academy, namely: either teach 180 days per year, or complete the curriculum for the grade level listed above; to keep a report card showing subjects taught, and grades earned in each subject, and an attendance record; to submit a copy of the report card to the Director at the end of each semester and the attendance record at the end of our school year; to keep in our home a portfolio consisting of a list of materials used and samples of student's work; and to provide for testing or an evaluation of our student and submit a copy of the results to the Director at the end of our school year.

We understand that Allendale Academy is a private school whose purpose is to provide parents with the opportunity to instruct their children at home. We understand that any advice given by the school and its officers and director is not guaranteed by the school. We release Allendale Academy from any liability. We assume all responsibility for compliance with all requirements with regard to education in our state. We understand Allendale Academy is not liable for any neglect on the parent's part. We understand, if we withdraw from Allendale Academy, our financial obligations must be met before our student's records will be released.

Signed:___________________________         Signed:__________________________