Ezekiel Preparatory Academy Bloom and Grow Garden Admissions Application & Enrollment Intake
Comprehensive admissions and enrollment intake form for EPA. Please complete all required fields, provide requested documents, and review the certification before signing.
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Student
*
Please Select
Mother
Father
Guardian
Stepparent
Grandparent
Other
Email Address
*
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Street Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other
ZIP Code
*
Preferred Method of Communication
*
Please Select
Phone
Email
Text
Employer
Emergency Contact Name
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
*
Student Information
Student Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name / Nickname
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Gender
*
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
Race / Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Middle Eastern or North African
Prefer not to say
Other
Current Grade Level
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Grade Applying For
*
Please Select
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Current School (if applicable)
School District
*
Student Photograph
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Eligibility & Special Education Information
Has your child been diagnosed with Autism Spectrum Disorder (ASD)?
*
Yes
No
Autism Diagnosis Documentation
*
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Does your child currently have an Individualized Education Program (IEP)?
*
Yes
No
Current IEP
*
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Does your child have a 504 Plan?
*
Yes
No
504 Plan
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Which services does your child currently receive?
Speech Therapy
Occupational Therapy
Physical Therapy
ABA Therapy
Counseling
Social Skills Training
Other
Describe the accommodations and supports your child currently receives
*
Academic Background
Current academic placement and relevant academic information
*
Most recent report cards or progress reports
*
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Most recent evaluation reports
*
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Medical & Health Information
Primary Care Physician Name
*
Primary Care Physician Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Allergies
Current Medications
Medical Conditions
Immunization Record (Georgia Form 3231) and Georgia Eye, Ear, Dental, and Nutrition Form 3300
*
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Behavioral & Support Information
Present behavioral concerns
*
Behavior interventions that have been effective
*
Are there any safety concerns we should know about?
*
Yes
No
Please provide details about the safety concerns
Placement & Scheduling Preferences
Desired Start Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Schedule/Program
*
Fees & Funding
Is the student currently receiving the Georgia Special Needs Scholarship (GSNS)?
*
Yes
No
Student's GSNS ID Number
Current GSNS Participating School
Payment Method
*
Scholarship
Self-Pay
Other
Parent Partnership & School Expectations
I understand EPA is a specialized private school serving students with autism and IEPs.
*
Acknowledge
I agree to participate in required parent meetings and conferences.
*
Acknowledge
I agree to provide requested educational records.
*
Acknowledge
I understand admission decisions are based on whether EPA can appropriately meet my child's needs.
*
Acknowledge
Required Document Uploads
Birth Certificate
*
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Immunization Record (Georgia Form 3231)
*
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Georgia Eye, Ear, Dental, and Nutrition Form (3300)
*
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Autism Diagnosis Documentation
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Current IEP
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Most Recent Evaluation Reports
*
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Report Cards / Progress Reports
*
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of
Custody Documents
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Additional Supporting Documents
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Enrollment Interest
How did you hear about Ezekiel Preparatory Academy?
*
Why are you interested in enrolling your child at EPA?
*
What are your hopes for your child's educational experience at EPA?
*
Parent Certification & Electronic Signature
Certification Statement
Parent/Guardian Electronic Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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