Admissions Application

Applicant name*

First name Last name

Applicant email address*

Which program are you applying to?*

Which school year are you applying for?*

Student information

Student name*

First name Last name

Place of birth*

City State / Province / Region Country

Gender*

Age*

Date of birth*

Home address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary language

If applicable, please indicate child's diagnosis(s)

ASD

Dyslexia

Down Syndrome

ADD

ADHD

GAD

Other

If you answered other, please explain

Primary contact information

Parent or guardian name*

First name Last name

Relationship to student*

Parent or guardian address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred phone*

Parent or guardian email*

Name of employer*

Job title*

Employer address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary contact information

Parent or guardian name (secondary contact)

First name Last name

Relationship to student (secondary contact)

Address (secondary contact)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred phone (secondary contact)

Email address (secondary contact)

Name of employer (secondary contact)

Job title (secondary contact)

Employer's address (secondary contact)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical history

Conditions: (check all that apply)

Allergies

Asthma

Mental Health Diagnosis

Special Diets

Seizures

Please explain further if you checked any of the above

Current medications (name, dosage, prescribed by)

Serious hospitalizations and age of hospitalization

Please describe your child's current health

Generally excellent

Good

Fair

Poor

Comments to child's health condition

Complete your online application

Student information

Primary contact information

Secondary contact information

School history

Medical history

Family history

Select payment method

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