APPLICATION FOR ADMISSION/INITIAL ASSESSMENT

Start Date

MonthDayYear
Date
Acceptance/Denial Letter Sent:
APPLICATION FOR ADMISSION/INITIAL ASSESSMENT
The Oberle Academy 404 Willis Street P.O. Box 801 Fredericksburg, VA 22404 2023-2024
STUDENT
REVIEW DATE

MonthDayYear
Date
BIRTHDATE

MonthDayYear
Date
AGE
RACE
GENDER
PARENTIGUARDIAN 1
PHONE
EMAIL
example@example.com
PARENT/GUARDIAN 2
PHONE
EMAIL
example@example.com
STUDENT ALLERGIES:
ADDRESS
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
Services
Original Date

MonthDayYear
Date
Diploma
Copy of Latest Eligibility Documents

Primary Disability / Secondary
Date

MonthDayYear
Date
Date

MonthDayYear
Date
FSIQ
Processing
Date

MonthDayYear
Date
Rdg
Math
Writing
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Copy of Student Attendance (Year to Date) Copy of Student Discipline Record (Including Year to Date Suspensions and Reasons for Suspensions) Copy of Physician's Certificate (Physical) with Doctor's Signature Up-To-Date Immunization (Shot) Record (Please record date of immunization) HepB (11-15Yrs) Tdap (7th)HPV (7th) MenACWY (7th/12th)

Copy of Up-To-Date Student Transcript
Grade Level
Administrator
Case Manager
Counselor
SOL TESTING RESULTS:
Earth Science Biology Algebra I Geometry World History I VA/US History English 11 Reading English 11 Writing

Report Card Date: English Math Science
Additional Notes
Should be Empty: