K-12 APPLICATION

K-12 APPLICATION

For all children Kindergarten - 12th
Student Full Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
Address*

Street Address

Apartment/Unit #

CityState / Province

Postal / Zip Code
Place of Birth*
DOB*
Race*
Sex*
Birth certificate*

Cancelof
Parent Full Name*

First NameMiddle NameLast Name
Date

MonthDayYear
Date
same as child
Address:

Street Address

Apartment/Unit #

CityState / Province

Postal / Zip Code
Phone*
Email*
Last Know School*

Young Kidz AcademyIf Other type School Name
Date Last School Enrolled

MonthDayYear
Date
Number Days Attended
Days Absent
Date withdrawn

MonthDayYear
Date
Course and Record of Achievement
Program Achievement
Date of Graduation

MonthDayYear
Date
School Address:

Street Address

Apartment/Unit #

CityState / Province

Postal / Zip Code
Speech TherapyEmotional or Behavior DisabiltyIEPDocumenting a Child’s DiagnosisSpecial Needs
Speech Therapy

Language Impairment Language impairments are disorders of language that interfere with communication, adversely affect performance and functioning in the student’s typical learning environment, and result in the need for exceptional student education. A language impairment is defined as a disorderin one or more of the basic learning processes involved in understanding or in using spoken or written language. These include: phonology, morphology, syntax, semantics, pragmatics.
Emotional or Behavior Disabilty

A student with an emotional/behavioral disability who has persistent (is not sufficiently responsive to implemented evidence-based interventions) and consistent emotional or behavioral responses that adversely affect performance in the educational environment that cannot be attributed to age, culture, gender, or ethnicity.
IEP

A student may qualify for the scholarship with an Individualized Education Plan (IEP) identifying one of the conditions above, approved by their school district within the past three years, in accordance with the rules of the Florida Board of Education or the rules of another state
Documenting a Child’s Diagnosis

A diagnosis validated by one of the following medical or mental health professionals:
- Physician licensed in Florida or another state or territory of the United States (includingthe District of Columbia or Puerto Rico)
- Florida-licensed Autonomous Advanced Practice Registered Nurse
- Florida-licensed psychologist)
Special Needs
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