APPLICATION FOR ADMISSION

Complete ALL fields

Grade Entering: _______ School Year: 20 ____ - ____ Today’s Date: ___ / ___ / ___

Child’s Legal Name: ________________________________________________ Nickname: ________________

Age: ____ Date of Birth: ___ / ___ / ___ Race/Ethnicity: __________ Birthplace: ________________________

(city, state/providence, country)

Gender: ☐Male ☐Female Citizenship*: ☐U.S. Citizen or ☐Other: Place of Citizenship: _______________

Person completing this application: _________________________________________ Relationship: ____________________

(Signature of Legal Guardian)

Child lives with: ______________________________________________________________________________

ADDRESS

Mailing: ______________________________________________________________________ (Apt. ______)

City: _____________________________________________ State: ___________ Zip: ________________

Physical address – If different from mailing address, please specify (no P.O. Box):

Street: ______________________________________________ City/State/Zip:______________________________

PARENT / GUARDIAN* CONTACT (circle one; legal guardians must provide documentation)

Mother/Guardian*: __________________________________________ Cell: ____________________________

Employer: __________________________________________ Work#: __________________________

Email: _____________________________________________ *If guardian, relationship:____________

Father/Guardian*: ___________________________________________ Cell: ____________________________

Employer: __________________________________________ Work#: __________________________

Email: _____________________________________________ *If guardian, relationship:____________

Home Phone: __________________________ Note: ________________________________________________

STEP-PARENTS OR GRANDPARENT(s) ☐Yes, permission to communicate w/SPs, GPs.
Legal guardian(s)? Yes* ☐ No ☐

Name: __________________________________________________ Phone: ___________________________

Name: __________________________________________________ Phone: ___________________________

*DOCUMENT REQUIRED

EMERGENCY CONTACT

Name: ________________________________________ City/Town: ______________________

Phone(s): ____________________________________________ Relationship: ___________________________________

School previously attended: ____________________________________________________ Grades: _______

Address: ________________________________________________________ Phone: _____________________

Has child repeated any grade? ☐no ☐yes If yes, which grade? _______

PROFESSIONAL ASSISTANCE

Does this child have any disabilities (physical or other) or limitation that might require adjustment to a normal student schedule? ☐no ☐yes If yes, please specify (and attach documentation*):

____________________________________________________________________________________________

Does this child have a learning disability or limitation that might require additional assistance? ☐no ☐yes

Does this child have an IEP in place? ☐no ☐yes If yes, please attach IEP*

If yes to either, please explain: ___________________________________________________________________

____________________________________________________________________________________________

DIAGNOSES

Please list any/all physical, mental, or emotional diagnoses? ___________________________________________

____________________________________________________________________________________________

MEDICAL HISTORY

Allergies: ☐no known allergies ☐allergies (please list all): ___________________________________________

Prescription Medications: ☐ none ☐ yes – If yes, please complete the medication form (include OTC meds)

Has this child been hospitalized over the past 12 months? If so, provide dates, and length of stay: _____________

Reason for hospitalization/ER visits: ________________________________________________________

COUNSELING (or similar)

Has child been treated for anxiety, or any mental or emotional disorder? (If so, please attach documentation*)

☐ no ☐ yes Reason (please explain): ___________________________________________________________

____________________________________________________________________________________________

Therapist-Counselor-Psychologist-Psychiatrist (circle one/more). Date last seen:_________ ☐*Documents attached

Professional Names & Location: _________________________________________________________________

CHURCH/SPIRITUAL How often do you attend services? ☐ weekly ☐ monthly ☐ occasionally _______

Religion/Beliefs: ______________________________________________________________________________

Church/Synagogue: ____________________________________________________ Location: _______________

Minister/Leader: __________________________________________ Phone/Email: _______________________

☐Yes, I authorize to contact/speak with our minister/spiritual leader. ______ (initial)