Application for Admission/Initial Assessment
2022-2023
Start Date
/
Month
/
Day
Year
Date
Interview/Tour Date
/
Month
/
Day
Year
Date
Acceptance/Denial Letter Sent
/
Month
/
Day
Year
Date
STI#
STUDENT
REVIEW DATE
/
Month
/
Day
Year
Date
START DATE
/
Month
/
Day
Year
Date
BIRTHDATE
/
Month
/
Day
Year
Date
AGE
GRADE
RACE
GENDER
PARENT/GUARDIAN 1
PHONE
EMAIL
example@example.com
PARENT/GUARDIAN 2
PHONE
EMAIL
example@example.com
ADDRESS
STUDENT ALLERGIES
LEA CONTACT
BASE SCHOOL
LEA PHONE
LEA EMAIL
example@example.com
LEA FAX
TO BE CONSIDERED FOR ACCEPTANCE, THE FOLLOWING RECORDS MUST BE PROVIDED WITH THIS APPLICATION FORM.
Copy of Current IEP including Addendums
Original IEP Date
/
Month
/
Day
Year
Date
Addendum Date
/
Month
/
Day
Year
Date
Services
Diploma Type
Eligibility Information
Copy of Latest Eligibility Documents
Minutes
Psychological Report
Educational Report
Sociocultural Report
Medical Report
Eligibility Date
/
Month
/
Day
Year
Date
Primary Disability / Secondary
Primary Disability / Secondary
Psychological Report Date
/
Month
/
Day
Year
Date
FSIQ
Verbal
Nonverbal
Working Memory
Processing
Educational Report Date
/
Month
/
Day
Year
Date
Reading
Math
Writing
Sociocultural Report Date
/
Month
/
Day
Year
Date
Medical Report Date
/
Month
/
Day
Year
Date
Please check if included:
Copy of Student Attendance (Year to Date)
Copy of Student Discipline Record (Including Year to Date Suspensions and Reasons for Suspensions)
Copy of Up-To-Date Transcript
Copy of Physician's Certificate (Physical) with Doctor's Signature
Copy of Up-To-Date Immunization (Shot) Record
Grade Level of Up-To-Date Transcript
Date of Administration MenACWY (7th/12th)
/
Month
/
Day
Year
Date
Date of Administration Tdap (7th)
/
Month
/
Day
Year
Date
Date of Administration HPV (7th)
/
Month
/
Day
Year
Date
Date of Administration HepB (11-15Yrs)
/
Month
/
Day
Year
Date
Administrator
Case Manager
Counselor
SOL TESTING RESULTS
SOL TESTING RESULTS:
SOL Test
Date
Score
To Take/Retake
Earth Science
Biology
Algebra I
Geometry
World History I
VA/US History
English 11 Reading
English 11 Writing
Most Recent Report Card Date
English Grade (Please include percentage)
Math Grade (Please include percentage)
Science Grade (Please include percentage)
History Grade (Please include percentage)
PE Grade (Please include percentage)
Additional Notes
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