Today’s Date:

Office Use Only Custody Medical

Photo Y - N

Student Emergency Information Record
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Students Name: (Last name, First name) Sex Ethnicity Birth Date
______________________________________________________________________________

Address:_______________________________________________________________________
______________________________________________________________________________

City: State: Zip Code:
______________________________________________________________________________

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Parent / Guardian Home Number: Work Number: Cellular Number:
1._____________________________________________________________________________
2.______________________________________________________________________

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Other Students residing at the same address: ________________________________________________________________________________________________

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The school will only release your child to the people listed below:
Name: Relationship to student: Phone number:

Alternate Phone: 1.______________________________________________________________________________________________ 2.______________________________________________________________________________________________
3.______________________________________________________________________________________________
4.______________________________________________________________________________________________

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Health Alerts
________________________________________________________________________

Doctor’s note required if recess or physical education restrictions are needed.
MEDICAL RELEASE – In case of an accident or serious illness, I hereby authorize Trillium Academy to follow their emergency medical care procedures. The school will attempt to contact me. If the school is unable to reach me, or the emergency contact names listed above I hereby authorize Trillium Academy to make medical decisions related to my child, this includes calling 911. I agree to pay all expenses incurred by the emergency care provided.
Health information provided on this form and information submitted on physical health appraisals may be shared with school personnel who are involved with the health and safety of my child.

Physician’s Name: _____________________________________ Office Phone: ______________ Parent Signature: ______________________________________ Date: _____/______/______

*** PLEASE FILL OUT BOTH SIDES***

Please note any custody arrangements:
______________________________________________________________________

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Publication Consent: Trillium Academy utilizes social media to share the programs and experiences of our school community with you as parents as well as promoting high quality educational opportunities for our students. Our performances, student’s activities, and other educational experiences will be shared through our school social media including the website, Facebook, news, and social media, etc. Please understand that we ask your permission below to utilize photos that include your child in these publications. While we refrain from using photos highlight just all of our school performances, athletic events, and school events such as assemblies, etc. will be photographed and publicized. By allowing your child to participate in these programs you accept that your child will be included in those publications.

By signing below I acknowledge that I have read and understand the media release guidelines and
____ I do NOT give permission for my child to be highlighted as an individual in photo opportunities, but understand they may be included in group photo opportunities.
____ I give permission for my child to be highlighted as an individual in photo opportunities, and understand that they may also be included in group photo opportunities.

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Students That Drive To School

Yes No I give permission for my child to drive home from school when ill or for emergency purposes after a parent/guardian is contacted via phone from school office.
Yes No I give permission for my child to drive their siblings from school when ill or for emergency purposes after a parent/guardian is contacted via phone from school office.

If student has permission a parent/guardian must sign this section in front of school official.

Parent/Guardian Name: __________________________________ Date ____/_____/____ Parents E-mail address ____________________________________

Primary Language Used in the home__________________________

TRILLIUM BOARD OF DIRECTORS

Mission Statement
Cultivating college and career focused learners by embracing academic excellence, strong character values, disciplined artistry, and individual student passions.

Agenda

Regular Meeting – September 27, 2017
8:00am

Trillium Academy
Conference Room 109
15740 Racho
Taylor, MI 48180
734-374-8222

Call to Order By: At:

Roll Call R. Bovitz S. Schwartz
G. Handel L. Green
T. Walker S. Wisinski
H. Gardner

Affirmation Trillium Board of Directors reaffirms the mission
of Mission statement.

Approval of Agenda The Board will either approve the agenda as presented or amend the agenda with the Approval of the Board.

Student Presentation Volleyball
Call to the Public The meeting is a meeting of the Board of Directors in public for the purpose of conducting the Academy’s business and is not considered a public community meeting. Those that may wish to address the Board on agenda items only may do so at this time by being recognized by the chair. There will be a second Call to the Public near the end of the agenda where interested parties may address the Board on any items of their choice. Those that request to address the Board have a maximum of three minutes in which to speak.

Consent Item I. Approval of the minutes from the August 30, 2017.
(Attachment 1)

Treasurer’s Report Approval of the Board Treasurer’s Report August 2017.
(Attachment 2)

Educational ESP Report
Service Provider’s S. Paddock; Interim Superintendent.
Report

Discussion Items Third grade reading requirements.

Action Items

CMU Representative Report (No Attachment)

Call to the Public Interested parties may address the Board on any items of their choice. Those that request to address the Board have a maximum of three minutes in which to speak.

Announcements The next Regular Board of Director’s meeting will be held on October 25, 2017 at 8:00am. in Conference Room 109.

Adjournment Motion By:
Seconded By:
Time:

Signed: __________________________
Signed by Steve Paddock (TRG) interim designee for Angela Romanowski, Superintendent

The above minutes were duly adopted by Trillium Academy Board of Directors
at a properly noticed open meeting at which a quorum was present.

Approved: ___________________________
Approved by Lisa Green, Board Secretary
These meetings of the Board of Directors are in public for the purpose of conducting the school’s business and are not to be considered a public community meeting. There is a time for public participation during each meeting as indicated in the agenda.

Upon request to the academy office, the academy shall make reasonable accommodations for a person with a disability to be able to participate in this meeting.

TRILLIUM BOARD OF DIRECTORS

Mission Statement
Cultivating college and career focused learners by embracing academic excellence, strong character values, disciplined artistry, and individual student passions.

Agenda

Regular Meeting – August 30, 2017
8:00am

Trillium Academy
Conference Room 109
15740 Racho
Taylor, MI 48180
734-374-8222

Call to Order By: At:

Roll Call R. Bovitz S. Schwartz
G. Handel L. Green
T. Walker S. Wisinski
H. Gardner

Affirmation Trillium Board of Directors reaffirms the mission
of Mission statement.

Approval of Agenda The Board will either approve the agenda as presented or amend the agenda with the Approval of the Board.

Student Presentation N/A
Call to the Public The meeting is a meeting of the Board of Directors in public for the purpose of conducting the Academy’s business and is not considered a public community meeting. Those that may wish to address the Board on agenda items only may do so at this time by being recognized by the chair. There will be a second Call to the Public near the end of the agenda where interested parties may address the Board on any items of their choice. Those that request to address the Board have a maximum of three minutes in which to speak.

Consent Item I. Approval of the minutes from the July 26, 2017.
(Attachment 1)

Treasurer’s Report Approval of the Board Treasurer’s Report July 2017.
(Attachment 2)

Educational ESP Report
Service Provider’s S. Paddock; Interim Superintendent.
Report

Discussion Items Process for Check Signatures
Update on Refinace of Debt
Update on Upcoming School Year

Action Items Contract Amendment No. 2

CMU Representative Report (No Attachment)

Call to the Public Interested parties may address the Board on any items of their choice. Those that request to address the Board have a maximum of three minutes in which to speak.

Announcements The next Regular Board of Director’s meeting will be held on September 27, 2017 at 8:00am. in Conference Room 109.

Adjournment Motion By:
Seconded By:
Time:

Signed: __________________________
Signed by Steve Paddock (TRG) interim designee for Angela Romanowski, Superintendent

The above minutes were duly adopted by Trillium Academy Board of Directors
at a properly noticed open meeting at which a quorum was present.

Approved: ___________________________
Approved by Lisa Green, Board Secretary
These meetings of the Board of Directors are in public for the purpose of conducting the school’s business and are not to be considered a public community meeting. There is a time for public participation during each meeting as indicated in the agenda.

Upon request to the academy office, the academy shall make reasonable accommodations for a person with a disability to be able to participate in this meeting.

TRILLIUM BOARD OF DIRECTORS

Mission Statement
Cultivating college and career focused learners by embracing academic excellence, strong character values, disciplined artistry, and individual student passions.

Agenda

Regular Meeting – July 27, 2016
8:00am

Trillium Academy
15740 Racho Rd
Taylor, MI 48180

Call to Order By: At:

Roll Call R. Bovitz S. Schwartz
G. Handel L. Green
T. Walker S. Wisinski
H. Gardner

Affirmation Trillium Board of Directors reaffirms the mission
of Mission statement.

Approval of Agenda The Board will either approve the agenda as Presented or amend the agenda with the Approval of the Board.

Student Presentation N/A

Call to the Public The meeting is a meeting of the Board of Directors in public for the purpose of conducting the Academy’s business and is not considered a public community meeting. Those that may wish to address the Board on agenda items only may do so at this time by being recognized by the chair. There will be a second Call to the Public near the end of the agenda where interested parties may address the Board on any items of their choice. Those that request to address the Board have a maximum of three minutes in which to speak.

Consent Item I. Approval of the minutes from the June 29, 2016 meeting.
(Attachment 1)

Treasurer’s Report Approval of the Board Treasurer’s Report June 2016.
(Attachment 2)

Board Committee
Reports/Board
Individual Comments

Educational D. Schulckbier, TRG; A. Romanowski,
Service Provider’s Superintendent.
Report

Discussion Items Future Facilities Needs
Matrix and Strategic Plan

Action Items Relationship with Darnell

CMU Representative Report No Attachment

Call to the Public Interested parties may address the Board on any items of their choice. Those that request to address the Board have a maximum of three minutes in which to speak.

Announcements The next Annual Board of Director’s meeting will be held on August 31, 2016 at 8:00a.m. in Conference Room 109.

Adjournment Motion By:
Seconded By:
Time:

Prepared: __________________________
Prepared by Will Kneer (TRG) interim designee for Angela Romanowski, Superintendent

The above minutes were duly adopted
by Trillium Academy Board of Directors
at a properly noticed open meeting at which a quorum was present.

Approved: ___________________________
Approved by Lisa Green, Board Secretary
These meetings of the Board of Directors are in public for the purpose of conducting the school’s business and are not to be considered a public community meeting. There is a time for public participation during each meeting as indicated in the agenda.

Upon request to the academy office, the academy shall make reasonable accommodations for a person with a disability to be able to participate in this meeting.