Application for Enrollment
at The Learner's Collective
Personal Information
Learner's Name
*
First Name
Last Name
Nickname or Preferred Name
If different than name listed above
Gender
Pronouns
Student's Birthday
*
-
Month
-
Day
Year
Date
Primary Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Address (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Learner's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Learner's Email
Siblings
*
Names, ages
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Guardian Information
Name
*
First Name
Last Name
Relationship to Learner
*
Partner/Spouse
First Name
Last Name
Relationship to Learner
Other Adult/s Involved in the Care of the Learner
First Name
Last Name
Primary Guardian Email
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Employer (if applicable)
Primary Caregiver
Current Job Title
Primary Caregiver
Name of Employer (if applicable)
Second Caregiver
Current Job Title
Second Caregiver
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Health Information
Primary Care Provider
*
PCP Phone Number
*
Please list any medications here:
Not required
Does your learner have a history of any of the following:
*
Diabetes
Heart disease
Kidney disease
Anaphylaxis
Sickle cell anemia
Asthma
Seizure or seizure disorder
Other, please elaborate below
No
If yes to any of the above, please elaborate.
Will your learner need medical support while they are in attendance at The Learner's Collective?
*
Yes, please elaborate below
No, they handle all medications themselves
No, no medications necessary
If you selected yes above, please elaborate
We will not be able to administer or store any medication for our learners.
Has your learner been diagnosed with any of the following? You may choose more than one:
*
Autism Spectrum Disorder
Depression
Anxiety/GAD/Social Anxiety/etc.
Sensory Processing Disorder
OCD
Other
ADHD
No
If yes or other above, please provide us with any additional information you deem relevant.
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Educational Background
Grade for the 2023-2024 School Year
*
If homeschooling, use your best judgement
Schools Previously Attended (including homeschool co-ops), Years Attended
*
ex: Clarke Middle, 2020-2021; Athens Montessori, 2021-2022
Do you have access to your learner's transcripts?
Yes, we can send a copy
No, but we can acquire them
No, my learner doesn't have a transcript
Transcripts
Browse Files
Drag and drop files here
Choose a file
If you have access to your learner's transcripts, please upload them here.
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Has your learner sat for any standardized tests?
Yes, they are a homeschooler who's taken ITBS/PASS
Yes, in a public/private school setting
No
Standardized Test Scores
Browse Files
Drag and drop files here
Choose a file
These results will only be used to establish benchmarks for your learner
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Has your learner ever been on an IEP, 504 Plan, or had other accommodation (including in a self-contained or non-inclusion classroom)?
*
Yes, an IEP or 504 plan
Yes, in a self-contained classroom
Yes, but it's not listed here
No
To the best of your ability and understanding, please explain what extra supports your learner requires.
Do you have suggestions about what supports or aids might help your learner thrive at The Learner's Collective?
Are you willing to meet with the leadership of The Learner's Collective in order to create a support plan for your student?
Yes
No, my student doesn't need support anymore
Is there anything else about your learner that we should know in order to better support and encourage them?
Ex: preferences, triggers, likes, dislikes, things they're excited about
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Extracurricular Activities
Current Extracurriculars (sports, music, hobbies):
If taking formal lessons, please list the organization (ie: trapeze at Canopy, piano at Athens School of Music)
Does the learner belong to any clubs?
Currently or in the last year
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