Application Form

Student Information

Student First Name

Student Middle Initial

Student Last Name

Residence Address

Mailing Address (if different)

Parent Email

Contact # during school hours

Student Birthday

Referred by (if applicable)

Enrollment Year

Emergency contact information

Please list the following for TWO separate people who could assume responsibility for your child should you not be available in case of emergency

Emergency Contact #1

Emergency Contact #1 First Name

Emergency Contact #1 Last Name

Emergency Contact #1 Phone Number

Emergency Contact #1 Address

Emergency Contact #2

Emergency Contact #2 First Name

Emergency Contact #2 Last Name

Emergency Contact #2 Phone Number

Emergency Contact #2 Address

Medical information

Please understand any medications that are dispensed to your child during the school day must be handed to us in its original prescription bottle

Name of medication #1

Dosage #1

Dispensing instructions/comments #1

Name of medication #2

Dosage #2

Dispensing instructions/comments #2

Name of medication #3

Dosage #3

Dispensing instructions/comments #3

Primary Care Doctor

Primary Care Address

Dentist

Dentist Address

Eye Doctor

Eye Doctor Address

Does your child wear glasses needed for school and or prescription contacts? if so, please list any instructions you need us to be aware of when it comes to these devices

Does your child have any health condition, mental health condition, medical diagnosis and/or learning disability? If so, please list appropriate diagnoses below:

If there are any custody situations that exist which provide stipulations for pick up or the like, please provide a copy of the court document so that the school staff can be aware and prepared should an emergency arise. All forms remain confidential.

I affirm that the information on this form is true to the best of my knowledge and understand that
false statements will be grounds for termination from the school.

Your Signature

Application requires a $20 non-refundable fee

Thanks for your application! a member of our staff will reach out shortly to continue the admissions process!