Magnolia Learning Academy

Child's Name

First NameLast Name

Child's Birth Date:

MonthDayYear

Address:

Street Address

Street Address Line 2

CityState

Zip Code

Child's Current School Name

School Name

Child's Current Grade

Grade

Mother's/Guardian's Name

First NameLast Name

Mother's/Guardian's Cell Phone Number:

Format: (000) 000-0000.

Mother's/Guardian's E-mail

example@example.com

Father's/Guardian's Name

First NameLast Name

Father's/Guardian's Cell Phone Number:

Format: (000) 000-0000.

Father's/Guardian's E-mail

example@example.com

Does the child have any special needs (ADD, Asperger’s, Dyslexia, etc.)

If you answered "YES" to the question above, please list the special needs of the child. (ADD, Asperger’s, Dyslexia, etc.)

Special Needs

Does your child currently receive any outside/in school services?

If you selected any of the above services, please list where your child is currently receiving those services.

What days of the week are you interested in your child attending?

Are you interested in enrolling as soon as possible or next school year?

Does your child have any allergies? (peanuts, chocolate, etc.)

If you answered "YES" to the question above, please list your child's allergies.

Allergies

Please describe your child's strengths and weaknesses:

My child appears to be more successful when.... (please include any items you think would help your child be most successful)

Do you agree to provide your own transportation for your child to and from school?

Referred by? Where did you hear about us?

Parent's/Guardian's Name

First NameLast Name

Signature

Interest Form