We’re excited that you’re considering North River Charter Academy for your child’s education! Please complete all required information carefully and upload any requested documents.

Please note that completing this form does not guarantee enrollment.

IF my child is covered by Medicaid and receives services under an Individual Education Plan (IEP), information may be used by the District to bill Medicaid for the following as established on the IEP:

• Behavioral or Health Services
  • Occupational
  • Physical
  • Speech-language therapy
  • Nursing
  • Augmentative services

IEP services are provided at no cost, regardless of consent.

Parental consent may be withdrawn at any time. Any billing authorization records disclosed are available upon request.

If my child is covered by Medicaid and receives services under an IEP, I consent for the District to bill Medicaid for those services provided.

By signing my name on the next screen, I accept responsibility to notify my child’s school of any changes of my home address and phone number.

I understand that EMS (911) will be called in the event of a serious accident or illness warranting evaluation and/or transport. I will assume responsibility for payment of EMS services.

In case of an accident or illness for which immediate treatment is not needed, but my child is unable to remain in school, I request that the school contact the parent(s)/guardian(s).

If unable to reach a parent or guardian, I request that one of the person(s) listed on my child’s Emergency Contact/Pick Up List to be contacted to pick up and/or care for my child.

I certify that the emergency and health information I have provided is true and accurate to the best of my knowledge.

I understand and agree that if my child has a health condition that may require management while he/she is in school that it is my responsibility to inform the school principal and/or school nurse of the health condition(s), provide a doctor-signed Medication Authorization Form, and discuss a plan of care.

By signing my name on the next screen, I understand and agree that information contained in this form may be shared with appropriate school staff, District partners, after-school programs, and healthcare professionals according to the Health Insurance Portability and Accountability Act (HIPPA).