Summer Application for Admissions
Student Information
Student
First Name
Student
Last Name
Gender
Please select...
Male
Female
Other
Birthdate
Current Grade in School
Please select...
Pre-K
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Ninth Grade
Tenth Grade
Eleventh Grade
Twelfth Grade
Type of School
Please select...
Public
Private
Home
Other
Please list the schools the applicant attended the last two years (Name of School, Street Address, City, State Zip and Grades Attended)
Is this child adopted?
Yes
Age adopted
Does this child live with both parents?
Yes
If the applicant does not live with both parents, what is the custody agreement for each parent?
Please list the name, age and present grade in school of other children in your family.
Please upload a recent photo of this student. This will only be used for the student file for identification purposes.
Parent/Guardian #1 Information
Parent #1 First Name
Parent #1 Last Name
Parent #1 Email
Parent #1 Mobile Phone
Parent #1 Work Phone
Parent #1 Home Phone
Parent #1 Street Address
Parent #1 City
Parent #1 State
Parent #1 Zip Code
Parent/Guardian #2 Information
Parent #2 First Name
Parent #2 Last Name
Parent #2 Email
Parent #2 Mobile Phone
Parent #2 Work Phone
Parent #2 Home Phone
Parent #2 Street Address (if different from Parent 1)
Parent #2 City
Parent #2 State
Parent #2 Zip Code
Please Describe:
Child's Favorite Activities
Child's Strengths
Social Relationships (Home/School)
Behavior and Attention at School
Response to Frustration
Other Information
Please check of all that apply:
Difficulty with reading
Difficulty with spelling
Difficulty with handwriting
Difficulty with school attendance
Difficulty with written language
Difficulty with fluency of writing
Difficulty with fluency in math
Difficulty with fluency in reading
Difficulty with abstract concepts
Difficulty with arithmetic
Difficulty with maintaining attention
Difficulty with organization
Difficulty with receptive language
Difficulty with expressive language
Other Education Concerns? Please list here:
Summarize any educational testing here:
Check all the apply:
Mental Health Condition
Received Counseling Services
Treatment for Mental Illness
Chronic or Serious Health Conditions
Taking Medications
Difficulty with Social Relationships
Been on a Behavior Support Plan
Been Suspended
Been Expelled
List any medical conditions here:
Summarize any psychological evaluations here:
Upload any psychological evaluation
Upload most recent IEP or 504 Plan
Upload the most recent educational evaluation
Upload most recent behavior plan
Upload current year report card or progress report
Contact Information
