APPLICATION FOR ADMISSION
Today’s Date
Preferred Start Date
PERSONAL INFORMATION
Child’s Full Name
First Name
Last Name
Child Goes By
Birthdate
Gender
Parent/Guardian
Mom's Name
First Name
Last Name
Mom's Phone Number
*
Mom's E-mail Address
example@example.com
Occupation/Title
Employer Name
Dad's Name
First Name
Last Name
Dad's Phone Number
*
Dad's E-mail Address
example@example.com
Occupation/Title
Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Secondary Phone Number
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation/Title
Employer Name
Primary Phone Number
Cell
Home
Work
Secondary Phone Number
Cell
Home
Work
E-mail Address
example@example.com
The applicant’s parents are
Married
Single
Separated
Divorced
Other
If applicable, who has legal custody?
Mother
Father
Joint
Other
With whom does the applicant reside?
Language(s) spoken in the home
Does your child have any allergies?
Yes
No
Please describe
Does your child require any medication during the school day?
Yes
No
Please describe
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ACADEMIC INFORMATION
Name of School
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Phone
Grade Level(s) Attended
Previous school your child attended
Name of School
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Phone
Grade Level(s) Attended
PARENT QUESTIONNAIRE
1. What can you tell us about your child that may help us to meet his/her needs?
a. Intellectually/Academically: Please consider topics such as language skills, number awareness/math ability, sustainedinterest in certain topics, persistence/follow-through)
b. Socially/Emotionally: Please consider topics such as emotional maturity, social compatibility, self-image, etc.
c. Physically: Please speak to topics such as motor skill development.
2. What do you expect from Acton Academy for your child? What do you hope your child will gain from a self-paced and learner driven environment?
3. If you see that your child isn’t doing their work or is struggling at school, how would you respond?
4. When it comes to education, how do you define success or failure for your child?
5. If your child has undergone any evaluations or assessments for academic, behavioural, social, or emotional needs, please list and explain.
6. If your child has ever needed extra support for academic or emotional needs (tutor, counsellor, therapist, psychologist, or physician), please expand.
7. Please provide any additional information you think will help us best serve your child if enrolled at Acton Academy.
The information on this application has been completed accurately and truthfully to the best of my knowledge.All legal guardians must sign.
Date
Parent’s/Guardian’s Signature
Date
Parent’s/Guardian’s Signature
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HERO QUESTIONNAIRE
**Please let your child answer these questions in his/her own words, even if parents help with typing. :)
Today’s Date
Your Name
What do you like to be called?
1. What do you like to do during your free time when you are inside?
2. What do you like to do during your free time when you are outside?
3. What books or stories do you love? Why?
4. What is the hardest part of being a good friend?
5. What do you like to learn about? How do you like to learn?
6. If you had $500 to spend on our learning environment, what would you want to buy? Why?
7. What do you like best about yourself?
8. What would you like to change about your life?
9. Is there anything else you want us to know about you?
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