Great Lakes Academy
46312 Woodward Ave. Pontiac, MI 48342 Phone: 248‑334‑6434 Fax: 248‑334‑6457
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Affirmation of Prior Discipline Record

Directions: Parent - Please select statement 1 or 2 below. Provide all appropriate information and submit form. You must print and sign the generated form.

A willful false statement of this affirmation may result in the student's non-enrollment or expulsion from Great Lakes Academy.

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Select One*

Required Input

The undersigned affirms that:
Student Full Name:*
Required Input

no matter his/her age or grade level, has NOT received any short-term or long-term suspensions, nor been expelled from any public or private school in Michigan or any other place for any disciplinary incident. This includes, but is not limited to, incidents involving weapons, alcohol or drugs, or the willful infliction of injury to another person or for any act of violence against persons and/or property committed on school premises, at any school-sponsored activity, or on a public or private conveyance providing transportation to and/or from a school or school- sponsored activity.
Student Full Name:*
Required Input

HAS received short-term or long-term suspension(s), or has been expelled from a public or private school in Michigan or any other place for any disciplinary incident(s). This includes, but is not limited to, incidents involving weapons, alcohol or drugs, or the willful infliction of injury to another person or for any act of violence against persons and/or property committed on school premises, at any school-sponsored activity, or on a public or private conveyance providing transportation to and/or from a school or school-sponsored activity.
Explanation:*
Required Input

Explain the circumstances in detail. Include the school name, dates of suspension(s) or expulsion, and a description of the incident(s) giving rise to the suspension(s) or expulsion.


Name of sending (former school):*
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Date student attended above listed school:*
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Input date as MM/DD/YYYY

Or select date from pop-up calendar
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Your Email:*
Must be a valid email address

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