Registration

1 General Information

2 Scholarship Information

3 Family Information

4 Student History

5 Medical Information

6 Student Pick Up Information

What Campus Are You Applying To*
Students Legal Name*
First Last
Does your child use another name?
SSN
Grade Last Enrolled
Date Of Birth
Date Format: MM slash DD slash YYYY
Date Enrolled
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Family Information
Parent/Guardian #1
First Last
Primary Phone
Home Address (if different than child's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Phone
Email Address
Parent/Guardian #2
First Last
Primary Phone:
Home Address (if different than child's)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Secondary Phone
Email Address:
Emergency Contact Information
Emergency Contact Person
First Last
Relationship To Child
Primary Phone Phone
Secondary Phone Phone
Secondary Emergency Contact Person
First Last
Relationship To Child
Primary Phone Phone
Secondary Phone Phone

Student History
Birthplace
Gender
Students Native Language
Siblings (Names & Ages)
Last School Attended
Last Grade Successfully Completed
Teachers Name
Address of School
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
School Phone
Was your child in an Exceptional Student Education Program at their last school?
Name of ESE Program(s): (co-taught, facilitated, mild, multi):
Does your student have an IEP (If yes please send a copy):
Does your child have a Written Behavioral Plan (FBA)

Medical History
What is your child's primary diagnosis?
Please list any of the child’s diagnoses and the dates they were made; included developmental as well as health related diagnoses. If necessary, use an extra sheet of paper. Please attach support documentation if available.
Diagnosis # 1
Date Diagnosed
Date Format: MM slash DD slash YYYY
Diagnosis # 2 (if applicable)
Date Diagnosed
Date Format: MM slash DD slash YYYY
Diagnosis # 3 (if applicable)
Date Diagnosed
Date Format: MM slash DD slash YYYY
Medication
Please list any medications the child is currently taking. If needed, please attach an additional sheet.
Medication # 1 Name
Dosage
Start Date
Administered At School?
Medication # 2 Name
Dosage
Start Date
Administered At School?
Medication # 3 Name
Dosage
Start Date
Administered At School?
Medication # 4 Name
Dosage
Start Date
Administered At School?
If additional medications, please indicate them here along with specific instructions or explanations of the medications listed above.
Physician
Primary Physician
First Last
Phone
Allergies
Food Allergies (Please List)
Medication Allergies (Please List)
Environmental Allergies (Please List)
Medical
Does Your Child Wear Glasses
Does Your Child Wear Contacts
Is your child currently medically stable?
If no please explain:
Is your child hard of hearing/deaf?
Does your child wear a hearing aid?
Is your child refuse food?

Student Pickup Information
The following people, other than the parents/guardians and emergency contacts listed above, may pick up my child from school:
Name
First Last
Phone
Driver's License Master Number:
Name
First Last
Phone
Driver's License Master Number:
Name
First Last
Phone
Driver's License Master Number:
Any other information you would like us to know about your child:
Parent's Name
First Last
Date
Date Format: DD slash MM slash YYYY
Signature

Scholarship Enrollment