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**Note that required fields are in bold**
First Name
Middle Initial
Last Name
Gender
Date of Birth
Calendar
Grade Level
Academic Interests
Parent/Guardian Name(s)

You may list both parents' name if applicable.

Email Address
Confirm Email

Must have 8 characters, at least one Upper Case letter, and at least one number.

Address Line 1
Address Line 2
City
State
Zip Code
Phone Number
Emergency Contact (Name)

in case of an EMERGENCY if Parents cannot be reached.

Emergency Contact (Relationship)

Relationship to student

Emergency Contact (Phone Number)
Emergency Contact (Email)
Does the student currently have any illnesses?
If yes, please describe. (If no, please type N/A)

If select "No" above, please type N/A in this field.

Is the student currently taking any medications?

If YES, please describe. If NO, please type NO.

Category
Will you be using Charter Instructional Funds?

We accept Charter Funds from Excel Academy and Valiant Prep for Summer Camps that start after July 2018. If you'd like to pay via Charter Funds, please have your class(es) selected and pay only the application fee portion at checkout. We will email you the charter fund payment instruction when we receive your application. To learn more, please call our office at (949)371-5785.

If yes, what is your Charter School?
If yes, who is your Charter Rep?
My Charter Rep's email
My Charter Rep's phone number
How did you hear about American Academy?
Able to learn and study independently

Parent states that, to the best of Parent’s knowledge, each Student registered by Parent is able to study independently in a quiet environment with minimum supervision and assistance. American Academy staff reserve the right to determine a student’s ability to study independently with minimum supervision and assistance.

Please Accept Terms and Conditions: By proceeding with the enrollment and class registration to American Academy of Strategic Education, you [hereafter, "User"] agree to the following conditions. PLEASE READ: *Financially responsible: Parent agrees to be personally financially responsible for the timely payment of all tuition owed for the length of the entire school year (September – June) for which the Student is being registered and enrolled. Parents may pay the entire tuition balance due for the year, make semi-annual payments, or make monthly payments. Parent also assumes all financial responsibility whether or not Student’s charter school ultimately agrees to pay such balance(s) *Consent to Treatment for Emergency Medical and Dental: ? As the parent, guardian, or authorized representative, I hereby give consent to American Academy of Strategic Education (hereafter “American Academy”) and its employees and volunteers to obtain all emergency medical or dental care as is deemed necessary for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of the child. *Insurance Disclaimer: American Academy does not carry health or accident insurance on its participants. All expenses incurred in the treatment of illness, injuries, or accidents will be the responsibility of the participant and his/her parents. I have read, understand, and accept the above conditions. *Consent to Photograph Release: My signature grants permission to American Academy the right to use and copyright photographs and video footage of my child without restriction for any professional purpose such as, but not limited to, promotion, advertising, and public relations. I hereby release and discharge American Academy and all affiliates from any and all claims and demands arising out of or in connection with the use of the photographs, including any and all claims for libel. If you would NOT like your child to participate in activities such as these, you must notify the academy, and they will ensure that your child is not photographed for the duration of the program. *Food Restrictions at the Academy: My child will not bring any snacks or food to the Academy that contain peanuts. Acknowledgment of Risk and Release and Waiver of Liability: As the parent or legal guardian, I acknowledge that there are certain risks inherent in my child’s participation in the American Academy. These risks include, but are not limited to, risks associated with travel to, from, and in and around our academy, and my child’s participation in supervised and unsupervised activities while at American Academy. I also acknowledge that any questions that my child or I may have about activities related to American Academy can be addressed to representatives of American Academy. I agree that I will inform an appropriate representative of the Academy of any special information regarding the health, or physical or mental condition of my child that may be relevant to my child’s participation at the Academy. In consideration for permitting my child to participate at the Academy, I hereby agree: (a) to release and discharge the Academy from any liability or responsibility for any personal or bodily injury, death, and for any damage to or loss of property, however caused, that my child or I suffer as a result of or in connection with my child’s participation at the Academy, including, without being limited to, any injury, loss, or damage resulting from, arising out of, or occurring in connection with the negligent acts or omissions of members of the faculty, staff, other employees, agents, or servants of the Academy; and (b) not to raise any claim or institute any legal action or proceeding, on my behalf or on behalf of my child, against the Academy for any cause of action that may result from or arise out of or in connection with my child’s participation at the Academy, for any personal or bodily injury (including death) to my child, including, without being limited to, injury, loss, or damage that may result from or arise out of or in connection with the negligent acts or omissions of members of the faculty, staff, other employees, agents, or servants of the Academy. All references to the Academy in this form will include, and all provisions of this form will insure to the benefit of the Academy’s officers, employees, agents, servants, and representatives. This acknowledgment of risk and release and the waiver of liability are governed by and will be construed in accordance with the laws of the State of California without regard to principles of conflicts of law. I agree that I will submit to the exclusive jurisdiction of the federal and state courts located in Orange County, California, for the resolution of all disputes arising hereunder or relating hereto, regardless of the place of execution of this form.
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