New Student Application

Name

First NameLast Name

Date

Childs Name

Grade

Matrix

Address

Home Phone

Cell Phone

Work Phone

Age

Date of Birth

Date

Place of Birth

Referred by

Adopted: Yes:No:Yes, at what age:

Yes at what age

Fathers Name

Age

Email address

example@example.com

Occupation

Last grade in school

Employer

Mothers Name

Age

Email address

example@example.com

Occupation

Last grade in school

Employer

Step Parent

Age

Email address

example@example.com

Occupation

Last grade in school

Employer

Child lives with

Family Income

Other children in home and ages

26240 Golden Maple Loop, Suite 101 Wesley Chapel, FL 813-949-0744 www.newleaps.org

Other

Self Pay

IEP

Behavior Plan

Service Plan

Transfer from current School

Home School

A What type of needs does this child have Give as many details as you can

B What do you think are the causes Is there a specific diagnosis

C Other earlier noticeable struggles list and give age at time

2. Which best describes your child?

Speed of Response to Questions: Average:

Necessity to Repeat Directions: Rarely:

Usually: Trouble buttoning and/or unbuttoning clothes:

3. Health History A. List in order or occurrence all illnesses, operations, injuries and health issues, e.g., allergies, asthma, frequent colds, etc. Give age and/or date when possible.

B Present Health Describe in detail

C List any physical limitations vision hearing speech etc

D List any significant illness of the parents or other adult household members Other childrens health

E. Is your child on medication?

If yes please list

Prescribed by whom

Dosage

Month

Year

F Name of Pediatrician and date of last examination

A. How would you describe your child? For example, is he/she: Sensitive:Shy/Timid: Rebellious: Aggressive: Stubborn:

Give details or examples to make clear what you feel are important immediately

B What are your childs strengths as you see them

C What are your childs weaknesses as you see them

5. Additional Comments: (Check or comment on any that might be present in your child)

Withdrawn or appears often to be daydreaming

Easily distracted by extraneous stimuli

Forms different associations than usual, making responses sound illogical or irrelevant

Sensitive to changes - responds with erratic behavior when faced with change

Has difficulty in remembering and following sequences

Has emotional problems that stem from years of misunderstanding, frustration and failure

Date

By Whom

Date

By Whom

Grades repeated

Reading level

Describe the above or any other special assistance needed

Has there been any change in adjustment Have there been any obstacles in entering school any fear or refusal to attend school inability to make friends difficulties participating in play Discipline concerns etc Special likes andor dislikes Please describe

C. Adjustment in school. Has there been any change in adjustment? Have there been any obstacles in entering school, any fear or refusal to attend school, inability to make friends, difficulties participating in play? Discipline concerns, etc.? Special likes and/or dislikes? Please describe:

7 List the professional persons or agencies with whom you have discussed your child

A. Mother's labor with this child? Normal:Prolonged: B. Child was: Full term: Late: C. Birth was: Natural: Caesarian:

D. Condition during the first two weeks?

Any other difficulty or abnormality

E. Early Nutrition: Breast fed:

F. Age when the following were attempted: Held head up:Rolled over: Crawled:Stood alone: Babbled:

Sat alone: Walked assisted: Used words:

G. Handedness of Child (left or right):

H Childs general disposition

I Any unusual fears

whom

When

K Is your child potty trained

L Further comments

This form is to be filled out by both parents and will constitute the application for admission to New L.E.A.P.S. Academy of Wesley Chapel, FL. The information provided will be used to evaluate your child, his/her potential and special needs and to be used to set goals. This information is entirely confidential, and will not be released to anyone other than school staff and personnel, unless requested by you. A pre-admission interview will be scheduled once this application has been completed, returned and reviewed by our staff. A Non-Refundable application fee of $50.00 will be charged prior to the phone interview. A Non-Refundable registration fee of: $250.00 will be charged at the time of the acceptance and enrollment.

Date

ParentGuardian Signatures

For internal purpose only

Date application received

Date

By

Appointment date and time set

Date

Contact info