School Admission Form
All applications will be considered as part of the ongoing admissions process throughout the year. Interview appointment to follow. Registration deposit secures enrollment. Enrollment forms and tuition payments to secure your scholar's spot will follow upon acceptance notification.
Scholar Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number
*
Without dashes
Gender
*
Please Select
Male
Female
Race/Ethnicity (select all that apply)
*
African-American
Alaska Native
Asian
American Indian
Hawaiian or Other Pacific Islander
Hispanic or Latino
White
Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does your child qualify for Special Education Services and is already identified with an Individual Educational Plan (IEP)? You will need to upload documents below
*
Yes, identified and has an IEP
No, Does not qualify
Does your child qualify for 504 and has a 504 plan in place? You will need to upload documents below
*
Yes, identified and has a 504 plan
No, Does not qualify
Does your child have a Behavior Intervention Plan (BIP), which is a formal, written plan designed to support students with behaviors that interfere with their learning or the learning of others, on file with their prior school? We will verify with the prior school.
*
Yes, you will be required to upload a recent BIP below.
No
Does your child have behavior, defiant, or discipline reports on file with their prior school? We will verify with the prior school.
*
Yes, single minor offense
Yes, single major offense
Yes, multiple minor offenses
Yes, multiple major offenses
No
List any in-school, after-school, and service activities your child is involved in:
*
If none type "N/A"
Name of last school
*
Phone Number
*
(if none type 0 in each field)
Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Last school School District
*
Phone Number
*
(if none type 0 in each field)
Format: (000) 000-0000.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization Formation
*
Public
Private
Charter
Other
Mode of Instruction
*
Please Select
Traditional In-Person
Online (Asynchronous)
Online (Synchronous)
Hybrid (Traditional/Online)
Last school result
*
Promoted (passed)
Failed
Reason for leaving last school
*
Admission sought as
*
Seedling K-2 Cohort
Sprout 3-5 Cohort
Bloom 6-9 Cohort
Canopy 10-12 Cohort (online)
Parent/Guardian Information
Parent/Guardian 1
*
First Name
Last Name
Parent/Guardian 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 1 Email
*
example@example.com
Parent/Guardian 1 Occupation
*
Gross Monthly Income
Before Taxes
Parent/Guardian 1 Place of Employment
*
Parent/Guardian 1 Work Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 (if none type N/A in each field)
First Name
Last Name
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Occupation
(if none type N/A in each field)
Gross Monthly Income
Before Taxes
Parent/Guardian 2 Place of Employment
(if none type N/A in each field)
Parent/Guardian 2 Work Number
(if none type N/A in each field)
Format: (000) 000-0000.
Select one of the following:
*
Parents are married
Parents are separated
Parents are divorced
Single Parent
Guardian
If divorced, select one of the following (required documents uploaded below):
*
Parents 1 and 2 have shared custody and are both allowed to be contacted regarding matters of the child, including but not limited to health, medical, academic, and pick-up.
Parents 1 and 2 do not have shared custody and only one parent is allowed to discuss matters of the child, including but not limited to health, medical, academic, and pick-up.
Parents 1 and 2 are currently in a legal custody.
Married with shared full custody, Does Not Apply.
Emergency Contacts
Parent(s)/Guardian(s) will be the primary contacts for all emergencies. Please provide other persons allowed to be contacted for emergencies.
Primary Emergency Contact
*
First Name
Last Name
This person is authorized to check out my child/children from NueroBloom Learning Lab. I understand I must call or send notice prior to the arrangement. I understand this person will have to present a valid form of government-issued identification.
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Secondary Emergency Contact
*
First Name
Last Name
This person is authorized to check out my child/children from NueroBloom Learning Lab. I understand I must call or send notice prior to the arrangement. I understand this person will have to present a valid form of government-issued identification.
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Interest in NeuroBloom Learning Lab
What are you interested in selecting NeuroBloom Learning Lab to provide an elite private school education to your child?
*
max 500 words
0/500
Documentation Upload
Attach Scan copy of recent Student Photo
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach Scan copy of Student Birth Certificate
*
Browse Files
Drag and drop files here
Choose a file
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of
Attach Scan copy of Last Report Card
*
Upload a File
Drag and drop files here
Choose a file
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of
Attach Scan copy of Academic Transcript
Upload a File
Drag and drop files here
Choose a file
You may obtain a recent copy from your current/previous school and upload/provide it before consideration.
Cancel
of
Attach Scan copy of Most Recent Individualized Educational Plan (IEP)
Upload a File
Drag and drop files here
Choose a file
You may obtain a recent copy from your current/previous school and upload/provide it before consideration.
Cancel
of
Attach Scan copy of Most Recent 504 Documentation
Upload a File
Drag and drop files here
Choose a file
You may obtain a recent copy from your current/previous school and upload/provide it before consideration.
Cancel
of
Attach Scan copy of Medical Clearance Certificate
Upload a File
Drag and drop files here
Choose a file
Request a letter from your child's pediatrician.
Cancel
of
Attach Scan copy of Medical Immunizations Record
Upload a File
Drag and drop files here
Choose a file
Request a letter from your child's pediatrician.
Cancel
of
Attach Scan copy of Child Custody Agreement (if divorced)
Upload a File
Drag and drop files here
Choose a file
Request a letter from your child's pediatrician.
Cancel
of
Parent/Guardian 1 Signature
*
Parent/Guardian 2 Signature
My Products
*
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NeuroBloom Learning Lab Admissions
Application Fee
$100.00
$
100.00
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