2023-24 Returning Student Registration for Re-Enrollment

2023-24 Returning Student Registration for Re-Enrollment
A School for Dyslexia and Learning Differences

Annual Tuition: $14,375

Application Fees $625 OR $775 (Itemized below)

_____$100 Non-refundable Early Bird Registration Fee (available January 2023 only) OR
_____$250 Non-refundable Registration Fee (After 5:00 PM on January 31, 2023)
_____$525 Program Fee

(Covers DePaul dress-down shirts, agenda, folders, disposable workbooks, one yearbook, club/elective classes, access to software at home and school, and two field trips.)

Please fill out the following and submit with your deposit. The remaining $525 fee is due by August 2023.
Student Name:
Birth Date

MonthDayYear
Date
Parent SSN
Race/Ethnicity:
Seeking Grade:
Psychoed Eval?
Gender:
Primary Mailing Address
Have you ever received a Step Up for Students Scholarship?
If so, please provide the ID#:
Primary Phone Numbers
Diagnosis: Please list all of your child’s learning differences and medical conditions.
Family and Custody Information
Mother/Primary Caregiver’s Name:
Mother’s Phone:
Mailing Address (if different from primary):
Mother’s Employer and Occupation:
Work Phone:
Mother's E mail (checked daily)
example@example.com
Mother's Custody Arrangement (full, partial, etc.; please provide documentation):
Mother’s Custody Arrangement (full, partial, etc.; please provide documentation):
example@example.com
Father/Primary Caregiver's Name
Father’s Phone:
Mailing Address (if different from primary):
Father’s Employer and Occupation:
Work Phone:
Father’s E-mail (checked daily):
example@example.com
Father’s Custody Arrangement (full, partial, etc.; please provide documentation):
Additional Medical Information/Emergency Information
Hospital Location of Choice
Phone
Medical/Allergy Alerts (chronic conditions, epilepsy, diabetes, etc.)
Emergency Contacts and Phone Numbers (other than primary caregivers listed above):
Name
Phone Number
Name
Phone Number
(Initial) blank _ I will assume full financial responsibility for emergency care and/or transportation for said child and will not hold the school financially responsible.
Doctor’s Name:
Dr. Phone:
Student’s Health Insurance:
Policy Number
Group Number
(Initial) blank _ I, the undersigned, authorize DePaul School to contact directly the persons named on this form and authorize the named physician to render treatment as is necessary in an emergency for the health of the child. In the event parents cannot be contacted, DePaul School staff is authorized to take whatever action is necessary in their judgment for the health of the child. I will assume full financial responsibility for emergency care and/or transportation for said child and will not hold the school financially responsible.
Prescription Medication: If your child requires prescriptions, please fill out the separate form and have it signed by your child’s doctor. Please make every effort to dispense prescriptions to your child outside of school hours. If you cannot, please fill out the separate form. All prescriptions must be in the original bottle with a current prescription date and correct information.

Non-Prescription Medication: Please request a Medication Permissions form from the office, fill out, and return with a doctor’s signature. You must also provide any medication we give your child, including vitamins and cough drops.

Pickup/Release Information:
I give permission to DePaul School to release my child to the following person(s) during the 2023-24 school year (in addition to primary caregivers):
Name as appears on Driver's License
Date of Birth

MonthDayYear
Date
Name as appears on Driver's License
Date of Birth

MonthDayYear
Date
Name as appears on Driver's License
Date of Birth

MonthDayYear
Date
Name as appears on Driver's License
Date of Birth

MonthDayYear
Date
Student Behavioral Survey

Please answer the following questions truthfully and thoroughly.
Name of Student:
In the last 3 years, has your child received any Needs Improvement or unsatisfactorymarks in conduct or behavior? Were you called to pick up your child from school due tobehavior? Please describe.
Does your child have referrals for behavior/conduct? Please describe.
Is there anything else about your child’s behavior that could affect his/her experience at DePaul?
I understand that DePaul is not a school that remediates behavioral issues or truancy. I further understand that my child must follow the DePaul Code of Conduct while a student at DePaul; work to resolve conflicts peacefully, behave honestly and
respectfully with students/teachers in person and online, refrain from distracting other students, follow adult directives to go to class, cooperate with staff, and follow all rules in the current edition of the Student Handbook, including that he/she must attend class when asked.

I further understand that tardies, early checkouts, and excessive absences may affect my child’s success in the program, and their ability to attain and keep scholarships.

If I falsify this document or fail to disclose behavioral information that negatively affects my child’s or another student’s DePaul experience, or if my child does not display growth when redirected, my student will be removed from the school.

I have read and understand 4/4 pages of this re-enrollment document.
Signature of legal guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

2023-24 Returning Student Registration for Re-Enrollment

Family and Custody Information

Additional Medical Information/Emergency Information

Emergency Contacts and Phone Numbers (other than primary caregivers listed above):

Student Behavioral Survey