Student Name
*
Please include First and Middle names
First Name
Last Name
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
(###)
###
####
Cell Phone
*
(###)
###
####
Applying for Grade
*
Birth Date
*
MM
DD
YYYY
Age
*
Gender
*
Male
Female
Current Grade
*
Current School
*
Dates Attended
*
MM
DD
YYYY
Parent/Guardian #1 Name
*
First Name
Last Name
Relationship to Student
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
(###)
###
####
Cell Phone
*
(###)
###
####
Email
*
Employer
*
Occupation
*
Parent/Guardian #2 Name
*
First Name
Last Name
Relationship to Student
*
Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
(###)
###
####
Cell Phone
*
(###)
###
####
Email
*
Employer
*
Occupation
*
Student resides with:
*
Parents
Mother
Father
Other
Please list any siblings the student has, along with their grade level and school.
*
1. Has your child ever been medically diagnosed with a learning difference, diagnosed with "ADD" or "ADHD", been recommended for counseling or special services such as occupational speech therapy, qualified for 504 eligibility, or received an Individual Education Plan (IEP)?
*
Yes
No
If "Yes," please explain and provide appropriate documentation.
*
2. Has your child ever received or been referred for mental health counseling or treatment?
*
Yes
No
If "Yes," please explain and provide appropriate documentation.
*
3. Does your child have a documented history of discipline or behavioral difficulties from a previous school?
*
Yes
No
If "Yes," please explain.
*
4. Has your child ever been suspended, expelled, or withdrawn from any school?
*
Yes
No
If "Yes," please explain.
*
5. Does your child have physical or medical conditions—i.e. special diets, prescriptions, allergies, or limitations of activity?
*
Yes
No
If "Yes," please explain.
*
Parent initials
*
Date
*
MM
DD
YYYY
