Victory Autism Academy Enrollment Application

Victory Autism Academy Enrollment Checklist

To complete your student’s enrollment application, please submit the following documents:

✅ Completed Victory Autism Academy Application (attached)

✅ Signed Student and Parent Acknowledgement Form

✅ Copy of Student’s Birth Certificate

✅ Most Recent IEP/MET or Medical Diagnosis

✅ Proof of Residency (e.g., utility bill with parent/guardian’s name and physical

address)

✅ Photocopy of Parent/Guardian’s Photo ID (e.g., driver’s license)
All documents must be submitted for the application to be considered complete.
Campus Selection
Please indicate the campus you are interested in enrolling your student at (check one):*
Student Information
Current School Attending:*
Grade Applying For:*
School Year Applying For:*
Student Full Name:*
Preferred Name/Nickname:*
Date of Birth:*
Gender:*
Ethnicity*
Phone Number:*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian Name (1):*
Relationship to Student:*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:*
example@example.com
Authorized to Pick Up:*
Parent/Guardian Name (2):
Relationship to Student:
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:
example@example.com
Authorized to Pick Up:
Student resides with:*

Both ParentsParent/Guardian 1Parent/Guardian 2Other
Are there any court orders, restraining orders, or other legal restrictions in place regarding individuals who are not permitted to have contact with your child?*
If yes, please provide the appropriate legal documentation to ensure school compliance and student safety.

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Medical and Social History
Primary Care Physician (Name, Phone Number, and Clinic/Practice Name):*
Psychiatrist (Name, Phone Number, and Clinic/Practice Name):*
Therapist (Name, Phone Number, and Clinic/Practice Name):*
ABA Provider (Name, Phone Number, and Clinic/Practice Name):*
Is your child currently under a physician’s care for a specific medical condition or concern? If yes, please provide details below:*
Do you have an advocate supporting your child's educational or medical needs? If yes, please provide their name and contact information: *
Has your child ever received a diagnosis for any of the following conditions?*

AnxietyDepressionSchizophreniaBipolar DisorderBorderline Personality DisorderOppositional Defiant Disorder (ODD)Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)None of the above
Has your child ever been hospitalized? If yes, please provide the reason(s) and date(s) below: *
Has your child ever shown signs of aggression toward themselves or others? If yes, please explain? *
Are there any strategies, supports, or incentives used at home that help your child manage their behavior effectively?*
Does your child typically sleep well through the night? If no, please explain:*
Health History
Seizure Disorder or Frequent Seizures: *
If yes, please indicate the type of seizure(s), frequency, duration, and medication(s):
Diabetes:*
If yes, please indicate current medication(s) and dosage/frequency:
Asthma:*
If yes, please indicate current medication(s) and dosage/frequency:
Heart, Blood, or High Blood Pressure:*
If yes, please explain:
Frequent Headaches or Migraines:*
Has your child ever experienced a head injury, major accident, or any significant trauma?*
If yes, please explain:
Hearing Impairment:*
If yes, please indicate degree of hearing loss, and if your child wear hearing aids:
Visual Impairment:*
If yes, please indicate degree of impairment and if your child wears glasses:
I agree to promptly inform Victory Autism Academy of any changes to my child’s medical conditions, medications, or dosages. I understand that such changes can significantly impact my child’s behavior and learning at school. I also acknowledge that this information may be shared with appropriate school personnel on a need-to-know basis in order to support my child’s safety and well-being within the school environment.*

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Date*

MonthDayYear
Date
Request for Giving Medication at School
List any medication your child takes during school hours. Indicate the medication name, dosage, time(s) administered, and reason for medication.
List any medication your child takes regular at home. Indicate the medication name, dosage, time(s) administered, and reason for medication.
Does your child have any known allergies?*
If yes, please list all known allergies (e.g. food, medication, environmental):
EPI-Pen*
I give permission for Victory Autism Academy staff to administer the medication(s) listed above to my child during school hours. I agree to notify the school promptly of any changes to my child’s medical conditions, medications, or dosages. I understand that changes in medication may significantly impact my child’s behavior and performance at school. I also acknowledge that this information may be shared with appropriate school personnel on a need-to-know basis to help ensure a safe and supportive learning environment for my child.*

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MonthDayYear
Date
Photo and Video Consent
During the school year, students may be photographed, recorded, or filmed by Victory Autism Academy staff while participating in school programs, events, and activities.

The purpose of this consent is to grant Victory Autism Academy permission to use and/or publish your child’s name, image, and/or creative works to support and promote the educational mission of the school. Examples of use include, but are not limited to:
- Yearbook
- School newsletters
- School website and social media (e.g., Facebook)
- Displays within the school or office
- Positive student recognition
By signing below, I acknowledge and provide the following consent:*

I DO authorize Victory Autism Academy to use, release, and/or publish my child’s name, image (in any form), and creative works through any medium—such as internet, print, and broadcast—for educational, promotional, or other related purposes without prior notice or compensation.I DO NOT authorize the use or publication of my child’s name, image, or creative works by Victory Autism Academy.
Legal Parent/Guardian Signature:*

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Date:*

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Date
Animal Therapy Consent
Victory Autism Academy incorporates live animals into educational and therapeutic activities as part of our student programs. Animals may include (but are not limited to): chickens, ducks, pigs, mini-ponies, bunnies, donkeys, and dogs. All animal interactions are closely supervised by trained staff; however, as with any animal interaction, there is a small risk of accidental injury.
By signing below, I acknowledge and provide the following consent:*

I DO give permission for my child to participate in Victory Autism Academy’s Animal Therapy Program. I understand and accept the potential risks involved and hereby release Victory Autism Academy and its staff from any liability for harm, injury, or accidents that may occur as a result of participation.I DO NOT give permission for my child to participate in the Animal Therapy Program.
Legal Parent/Guardian Signature:*

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Date
Agreement for Student use of Technology
Victory Autism Academy will strive to enforce all rules concerning student access to the Internet through the use of technology. The school will also make every attempt to keep all students safe from inappropriate information and/or contact while using technology. Victory Autism Academy has installed Barracuda Web filtering software, which is utilized by most of the school districts in the state to eliminate student access to objectionable materials, information, and sites. Each student is responsible for their own behavior and will be held accountable. Parents will be required to make a decision of whether or not to allow their child access to the Internet. All parties are aware of the consequences for inappropriate behavior or rule violations.

As a parent/guardian of this child, I have read the Parent/Student Agreement for Student Use of Victory Autism Academy Technology and Appropriate Use Policy for Student Access to the Internet.
- I recognize it is impossible for the school to restrict access to all objectionable material, and I will not hold Victory Autism Academy responsible for materials acquired or contacts made on the internet.
- I understand that students may have access to inappropriate information, and should my child access this information, I will not hold Victory Autism Academy liable for any harm it may cause.
- I understand that any conduct by my child that is in conflict with these responsibilities is inappropriate, and such behavior may result in the termination of any and all access to Victory Autism Academy’s technology, including the Internet, as well as possible disciplinary action.
- I have explained these responsibilities to my child and discussed the possible consequences for inappropriate behavior.
- I give permission to Victory Autism Academy to provide Internet access to my child.
I agree to pay any cost of repair to hardware and/or software that my child may damage through misuse. We ask parents to assist us in training students to help us care for this costly equipment. Our desire is to provide the very best resources available.
Legal Parent/Guardian Signature: *

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Date
Behavior Intervention Policy
Victory Autism Academy (VAA) staff strives for excellence in providing the highest quality educational programs for all students. We make every effort to provide a healthy, positive, and safe environment promoting academics, life skills, social skills, and positive behavior. We use a variety of behavioral and Crisis Prevention Intervention (CPI) techniques to ensure the care, welfare, safety, and security of all students, staff, and others in the educational environment are a top priority.

Physical intervention will only be used as a last resort where we deem a child to be putting themselves or others in immediate physical danger. Therapeutic holds and physical restraint will not be used unless less restrictive interventions appear insufficient to mitigate the imminent danger of bodily harm to the student or others.

Therapeutic holds will not impede the student’s ability to breathe and will not be out of proportion to the student’s age or physical condition. Therapeutic holds will end when the student no longer is a physical danger to themselves or others.

A therapeutic hold is defined as a treatment technique where a person in crisis is contained by a group of trained personnel rather than mechanical or chemical restraint.

Victory Autism Academy does not use “seclusion” as a form of intervention. Victory Autism Academy staff may, however, take a student on a walk to calm him or her, or provide an alternative area away from the classroom to maintain student dignity, and privacy, and to maintain the safety of peers.

Victory Autism Academy staff are trained in the use of physical interventions as well as de-escalation strategies. Physical interventions can be as subtle as a physical cue and as restrictive as a therapeutic hold. Victory Autism Academy staff are trained in therapeutic holds and are overseen by a Crisis Prevention Intervention trainer. Staff are fully trained each year and provided no less than two refreshers within the school year.

When a therapeutic hold occurs, the lead staff member who responded will document the incident on a therapeutic report form and administration will check the student for any injury that may have occurred during the intervention. Parents or guardians will be informed that day via phone call. Parents may request a copy of the incident report at any time. All incidents are tracked so that we analyze any patterns related to the behaviors that lead to physical interventions to develop, different techniques to prevent the behavior from occurring in the future, to determine whether a child may need extra support, and to develop replacement behaviors that will be taught to the student.

Consent for Crisis Prevention Interventions and/or Therapeutic holds

I understand and accept the above conditions, and I grant permission for the staff of Victory Autism Academy to utilize Crisis Prevention Interventions and/or therapeutic holds consistent with state and federal laws. Furthermore, I will contact Victory Autism Academy if I have any questions about behavioral interventions, Crisis Prevention Interventions, or therapeutic holds. I acknowledge that the signature of one legal parent/legal guardian is sufficient for these consents.
Student Name:*
Legal Parent/Guardian Printed Name:*
Legal Parent/Guardian Signature*

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Enrollment Document Uploads

Please upload or submit copies of the following required documents to complete your child’s enrollment application:
Photocopy of Parent/Guardian’s ID (e.g., driver’s license)

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Proof of Residency (e.g., utility bill with parent/guardian’s name and physical address)

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Copy of Student’s Birth Certificate

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Copy of Student's Immunization Records

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Most Recent IEP/MET or Medical Diagnosis (if applicable)

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Student and Parent Acknowledgement Form

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Should be Empty:

Campus Selection

Student Information

Parent/Guardian Information

Medical and Social History

Health History

Request for Giving Medication at School

Photo and Video Consent

Animal Therapy Consent

Agreement for Student use of Technology

Behavior Intervention Policy

Enrollment Document Uploads