2022-23 Returning Student Registration

2022-23 Returning Student Registration
A School for Dyslexia and Learning Differences

2022-23 Returning Student Registration Annual Tuition: $12,500 Application Fees (Total: $625)

$100 Non-refundable Registration Fee (required with this form to hold an enrollment slot) $525 Program Fee (includes two DePaul T-shirts, agenda, folders, disposable workbooks, one yearbook, club/elective classes, access to software at home and school, and two field trips

Acceptable forms of payment include check, ACH withdrawal, cash, or credit card.

All students must submit a current FL School Health Exam Form, a current immunization record, and copies of the birth certificate and social security card before August 1, 2022 to be eligible for enrollment. Please fill out the following and submit with your $250 deposit. The remaining $525 fee is due by August 2022.
Student Name:
Birth Date

Month Day Year
Date
Parent SSN
Race/Ethnicity:
Seeking Grade:
IQ (if known)
Gender:
Last School
Primary Mailing Address
Primary Phone Numbers
Diagnosis: Please list your child's learning differences, as well as any medical conditions that may affect your child's ability to learn.
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):
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
I will assume full financial responsibility for emergency care and/or (Initial) 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) 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.

I, the undersigned, authorize DePaul School to contact directly the 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

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.

I give permission to DePaul School to release my child to the following person(s) during the 2021-22 school year (in addition to primary caregivers list above):
Name as appears on Driver's License
Date of Birth

Month Day Year
Date
Name as appears on Driver's License
Date of Birth

Month Day Year
Date
Name as appears on Driver's License
Date of Birth

Month Day Year
Date
Name as appears on Driver's License
Date of Birth

Month Day Year
Date
Name as appears on Driver's License
Date of Birth

Month Day Year
Date
Emergency Contacts and Phone Numbers (other than primary caregivers listed above):
Name of Student:
Is there anything about your child’s behavior that could affect his/her experience at DePaul?
I have read and understand 4/4 pages of this re-enrollment document.
Signature of legal guardian

Clear
Date

Month Day Year
Date
Parent printed name
Should be Empty:

2022-23 Returning Student Registration

Family and Custody Information

Additional Medical Information/Emergency Information

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

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