2021-2022 BTE Discovery Institute Student Application

BTE 21st Century Discovery Institute

Student Enrollment Application
Additional Documents for Registration

Complete this registration form by July 31st to be considered for admission.

In additon to this form, you will need:
- Copy of Student's Birth Certificate
- Current Immunization Form
- Copy of any IEP or 504 Documentation
- Tuition Agreement (Provided after student acceptance)
- Medical Release Agreement (Provided after student acceptance)
- Media Release Agreement (Provided after student acceptance)
- Technology Use Agreement (Provided after student acceptance)
- Field Trip Experience Agreement (Provided after student acceptance)
Are you applying for enrollment as a Full Day or CO-OP student?

BALANCED (Full-Time Student) AROUND THE CLOCK (Full-Time + Extended Day and Fridays)
Student Information
Last Name
First Name
M.I.
Age
Gender
Ethnicity
Birth Date

Month Day Year
Parent's Email Address
Entry Year
Grade (21-22 School Year)
Entry Semester
Has your child ever been retained?

Yes No
Zoned School:
Current Residence Information
Street Address
Street Address Line 2
City
State
Zip Code
Home Phone Number
Cell Phone Number
Parent/Guardian Information
First Name
Last Name
Phone Number
Relationship to Student:
Are there any custodial issues that BTE Discovery Institute should be made aware of to protect the safety of the student?

Emergency Contact 1
Last Name
First Name
Primary Phone Number
Relationship to Student
Emergency Contact 2
Last Name
First Name
Primary Phone Number
Relationship to Student
Individuals Authorized to pick up student (include name, phone number and relationship)
Physician and Medical Information
Last Name
First Name
Primary Phone Number
Secondary Phone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Enrollment History
Previous School
School Name
City
State
Date Started

Month Day Year
Date Ended

Month Day Year
What prompted your decision to seek other options for your child's educational well- being?
Does your child have an IEP? (If yes, please provide documentation.)

Yes No
Does your child have a 504 plan? (If yes, please provide documentation.)

Yes No
Does your child receive gifted services? (If yes, please provide documentation.)

Yes No
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Upload any necessary files here:

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I agree to have members of BTE Discovery Institute contact me in regard to my student's registration status. I confirm that the information that I have provided is accurate. *

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