Ladies of Favor Dream Academy Application Form

I. General Information
Date of Application *

Month Day Year
Student Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Age *
State & County of Birth *
Primary Language In Home *
Present Address *

Street Address

Street Address Line 2

City State

Zip Code
Permanent Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent Full Name *

First Name Middle Name Last Name
Relationship *
Mobile Number *
E-mail *
Parent Full Name *

First Name Middle Name Last Name
Relationship *
Mobile Number *
E-mail *
example@example.com
Person to contact in case of emergency: *
Parent/Guardian
Relationship *
ex. Father, Mother, etc.
Present Address *

Street Address

Street Address Line 2

City State

Zip Code
Mobile Number *
Student Resides With? *
II. Educational Information
Last School Attended: *
Reason for Leaving: *
Student Academic Performance: *

Superior (A+) Above Average (A-B) Average (B-C) Below Average ( C-D) Poor (Failing)

Current Grades or Recent Grades from Previous School Year

Subject

Grade

Has Student Ever Failed or Repeated a Grade? (If yes, please provide details?): *
Has Student Ever Been Suspended or Expelled? (If yes, please provide details?): *
Has Student Ever Been Evaluated or Qualify for Exceptional Services (i.e. Special Education, Gifted etc.)? (If yes, please provide details?): *
Does Student Have an Individual Education Plan (IEP)?(If yes, please provide details and Start Date of Services?): *
Has Student Been Diagnosed with any Psychological, Mental, Emotional, and/or Behavioral Diagnosis? (If yes, please provide details.): *
Describe Students Behavior in School: *
III. Medical Information
Describe below all physical health conditions or illnesses which may limit the child's participation in programs or activities. ): *
Please List Any Medications Prescribed *
Please List Name and Address of Healthcare Provider *
Is your daughter currently seeing a counselor or therapist? *

Yes No
Please List Name and Number of Provider
IV. STATEMENT OF CHARACTER:
Please state why your daughter should be accepted into Ladies of Favor Dream Academy. Describe your daughters' attributes, achievements, and any additional information that will speak to her character and development. *
V: Recommendation

All applicants must provide at least one reference that attest to the character of the youth.
Name
Organization
Relationship
Phone Number & Email
Agreement & Signature:
I agree to allow Ladies of Favor Dream Academy to process personal information contained in this application for any purposes connected to accepting my child into the school.

I agree submitting this application does not gaurantee admission or enrollment into Ladies of Favor Dream Academy.

I certify that, to the best of my belief, the information I have provided is complete and true.
Signature of Applicant

First Name Last Name
Date

day month year
Should be Empty:

I. General Information

II. Educational Information

III. Medical Information

IV. STATEMENT OF CHARACTER:

V: Recommendation

Agreement & Signature: