Accelerate Academy Interest Form

REGISTRATION FOR CORE ACADEMIC PROGRAM

Grades 1–12 (9 AM–1 PM) 4-hour core day, Orton-Gillingham based instruction, max 6 students
I am interested in:*
Additional documents for registration consideration
- Bring this registration form and the following documentation to the school office.
- Copy of Certified Birth Certificate
- IEP/504 Documentation
- Current Immunization Form
- Current Proofs of Residence (ex. power, water or gas bill)
Student Information
Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Email Address
Phone Number
Please enter a valid phone number.
Grade
Parent Information
Parent/Guardian 1

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Parent/Guardian 2

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Student Residence Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Parent/Guardian 1 Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Residence Information (if different from above)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Previous School
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Notes
Please inform me of any other vital information you think they may need to know in the event of an emergency. Thank you.
Should be Empty:

REGISTRATION FOR CORE ACADEMIC PROGRAM