Application Date
Student's Full Name (First, Middle, Last)
Preferred Name
Complete Address
Phone
Email
Age
Birthday
Birthplace (City, State, Country)
Last school attended
Last Grade Completed
Last school address
Father/ Guardian Legal Name:
Address:
Employer:
Position:
Cell Phone
Mother/ Guardian Legal Name:
Address: (if different from father)
Employer:
Position:
Cell Phone
Marital Status:
Married
Divorced
Remarried
Separated
Divorced
Single
Children in family other than applicant:
Child Name and Age
Church attending
Pastor
Address
Phone
How do you provide spiritual training for your children in the home?
What goals do you have for the training and development of your children as individuals?
What are your reasons for wanting to enroll at Lakes Academy?
Briefly describe your child.
Is there anything that you think you should know about your child in order to teach or discipline him/her effectively?
Does your child have any physical, mental, or emotional handicaps that may affect his or her activities or progress that should be known?
Has a child care provider or teacher ever recommended your child for academic testing for learning disabilities or ADD/ADHD? Explain
Family Physician/ Pediatrician
Phone
Does your child have any physical disabilities or allergies? Explain.
Are there any diagnosed learning disabilities (dyslexia, speech, ADD, ADHD, etc) that require special treatment and/or programs?
Is your child on any medication? If so, please list medication and explain usage.
Father signature and date
Mother signature and date
Signature and date
Child’s latest report card or grade progress report
Child’s Birth Certificate
Child’s Immunization Record from Pediatricians office
Send
