Explorers Micro-School Application

Explorers Micro-School Application

Application for Explorers Micro-School, a Home Education Instructional and Enrichment Program for elementary-aged homeschool students. Please complete all required contact and safety details so our team can review your application and contact you about next steps.
Parent/Guardian Information
Parent/Guardian Full Name

First NameMiddle NameLast Name
Relationship to Child
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Contact
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Student Information
Student's Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Current Grade Level
Current Home Education Status
If other, please specify
Educational Background
Previous school or homeschool experience
Current curriculum used
Academic strengths
Areas where your child may need additional support
Reading level, if known
Math level, if known
Learning style
Student Interests
Favorite subjects
Hobbies and interests
Hands-on activities they enjoy
What do you hope your child will gain from Explorers Micro-School?
Social & Emotional Information
How does the student typically interact with peers?
How comfortable is the student in small group settings?
How well does the student follow directions?
How independent is the student?
Are there any behaviors, triggers, or situations staff should be aware of to best support the student?
Health & Safety
Allergies
Medical conditions
Medications staff should be aware of
Dietary restrictions
Emergency contact name

First NameMiddle NameLast Name
Emergency contact relationship to child
Emergency contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized pickup persons
Additional Support
Does your child have an IEP, 504 Plan, diagnosis, learning difference, or other support need?
If yes, please describe any diagnoses, learning differences, support needs, and helpful accommodations or strategies. This information is used only to help Explorers Micro-School support your child well.
Permissions & Consent
Permission for photo and video use in program communications and materials
Permission for participation in hands-on activities and enrichment experiences
Permission for participation in local educational outings and field experiences
Permission for staff to seek emergency medical care if a parent or guardian cannot be reached immediately
Electronic Signature
Parent/Guardian Full Legal Name

First NameLast Name
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Explorers Micro-School Application

Parent/Guardian Information

Student Information

Educational Background

Student Interests

Social & Emotional Information

Health & Safety

Additional Support

Permissions & Consent

Electronic Signature