School Enrollment Form

Brite Future Academy

This form is also available to download on our home page. You will need to bring in your school records, birth certificate and immunization records prior to first day of school. You may pay with cash, check, credit/debit card or ESA account. STO recipients can fill out either form, and payment will be handled directly with the STO.
Fall 2016 Online Enrollment

Mother / Guardian 1 - Information
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number:
Mobile Number:
Work Phone Number:
Email Address:
Employer with Address
Occupation:

Father / Guardian 2 - Information
Full Name

First Name Last Name
Address Same as above

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number:
Mobile Number:
Work Phone Number:
Email Address:
Employer with Address
Occupation:

Custody
Child Lives with

Both Parents Mother Only Father Only Split Custody Other
Special Custody Arrangements:

Emergency Contacts
Contact 1:Full Name

First Name Last Name
Relationship
Phone Number

- Area Code Phone Number
Contact 2: Full Name

First Name Last Name
Relationship
Phone Number

- Area Code Phone Number

Siblings and Others Living in Home
1: Name
Relationship
Age
Grade/School
2: Name
Relationship
Age
Grade/School
3: Name
Relationship
Age
Grade/School
4: Name
Relationship
Age
Grade/School
Student Info and History

Developmental Info
Pregnancy
Birth Weight: lbs and oz
Surgeries /Hospitalizations
Include approximate ages.

Rolling Over

	1	2	3	4	5
Early						Late

Sitting Up

	1	2	3	4	5
Early						Late

Crawling

	1	2	3	4	5
Early						Late

Cross Crawl or Variation like Bear Crawl

Walking

	1	2	3	4	5
Early						Late

Eating Pureed Foods

	1	2	3	4	5
Early						Late

Eating Small Finger Food: ie Cheerios

	1	2	3	4	5
Early						Late

Self Feeding

	1	2	3	4	5
Early						Late

Babble

	1	2	3	4	5
Early						Late

First Words

	1	2	3	4	5
Early						Late

Phrases

	1	2	3	4	5
Early						Late

Potty Trained

	1	2	3	4	5
Early						Late

Dry at Night

	1	2	3	4	5
Early						Late

Dress Self

	1	2	3	4	5
Early						Late

Do any family members have a history of the following?

Learning Difficulty Dyslexia or Reading Issues Obsessive Compulsive Disorder (OCD) ADD/ADHD Anxiety Addiction

Student Diagnosis or Conditions

	Suspected	Diagnosed	Medicated/Under Treatment	Treated
ADD/ADHD
Dyslexia/Reading Issues
Anxiety
Autism
Cerebral Palsy
Seizures
Poor Balance/Coordination
Delayed Language/Articulation Disorders
Strong Fears
Snoring/Sleep Apnea
Other:

Student Interests
Favorite Book
This may be book that parents read if child is not reading on own yet.
Favorite Book to Read/Explore
Favorite Movie
Favorite Character
Favorite Activity
Favorite Color
Favorite Animal
Favorite Foods
Least Favorite Foods
Foods they do not prefer to eat.
Dreams
Either what they dream about at night, or dream about during the day.
Unique Qualities
Upload a favorite photo of your child

Upload a File

Cancel of

Notes to School
Why are you looking for an alternative to Traditional Education?
How does your child currently occupy their time?
Describe your experience raising your child.
Birth Certificate Provided

Yes No
Immunization Records Provided

Yes No Waiver
Last School Report and Records provided

Yes No

Fees

Program Fees *

Pay in Person with cash, check or monthly payments. Free

Admissions Fee: Assessment Provided $ 150.00

Supplies Fee Full Time $ 250.00

Supplies Fee: Part Time $ 125.00

Standard Tuition: Year $ 7,600.00

Standard Tuition:Semester $ 3,850.00

Part Time Standard Year (discount) $ 4,500.00

Part Time Standard Semester $ 2,325.00

Homeschool Basic Family Plan: Prepay Year discount $ 1,200.00

Homeschool Basic Family Plan: Semester Discount $ 650.00

Resource Level One: Prepay year discount $ 17,500.00

Resource Level One: Semester Discount $ 8,800.00

Resource Level 2:Prepay Year Discount $ 22,500.00

Resource Level 2: Semester Discount $ 11,300.00

Brain Labs: Year $ 1,600.00

Brain Labs: Quarter $ 488.00

Brain Labs: Month $ 195.00

Enter coupon

Total: $ 0.00

Program Choice
E-mail
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Brite Future Academy

Fall 2016 Online Enrollment

Student Info and History

Health & Developmental Info