Text Box: APPLICATION FOR ADMISSION please provide complete and accurate answers

 

                                           

 

 

1855 LANSING ST. Melbourne,  florida 32935

321-751-1313

Text Box:     1855 LANSING ST. Melbourne,  florida 32935 321-751-1313

Text Box:   applicants full name:  _____________________________________________________________ Intent Confirmation number: ________________________Date filed____________ Matrix_______ date of birth  ____________ grade level  _____  social security  ________________ __________       address __________________________________ city & zip  __________________________________ home phone: _________________________ emergency phone: ______________________________   E-mail address __________________________________________________________________________ previous school  ______________________________________________district___________________ city, state, zip   ___________________________________________________________________________ principal  _____________________________________ phone:________________________ __________  

    

        

 

 

 

 

 

 


 

                                                      

 

mother □   step-mother □   guardian □                                father □ step-father  □  guardian □

 

Text Box: full name ____________________________________________      full name  ____________________________________________ address _____________________________________________      address ______________________________________________ city, state, zip________________________________________     city, state, zip ________________________________________ work phone __________________________________________      work phone   __________________________________________ cell phone ___________________________________________      cell phone   ___________________________________________ e-mail ________________________________________________      e-mail ________________________________________________ employer ____________________________________________      employer _____________________________________________ Social Security Number_______________________________     Social security Number________________________________ drivers license number_______________________________    drivers license number _______________________________ Text Box: for what reason do you wish to enroll your child in our school?  _____________________________________________________   ____________________________________________________________________________________________________________________ -  

 

 

 

 

 

 

 

 

 

 

 

 

 please list all counselors and therapist who have seen the applicant:

 

name: _______________________________________________       name:  ________________________________________________               

address: ____________________________________________       address: _____________________________________________

nature of service: ____________________________________        nature of service:  ________________________________                                                                           

age at time of service  ________                                                       age at time of service  ________

 

list any medical conditions?  _________________________________________________________________________________

 

has the applicant ever been hospitalized for physical or psychological reasons?     no □      yes □

if yes, please give date and reason:  _________________________________________________________________________

 

is the applicant required to take any medication?     no □   yes  □    if yes, please describe for what: ________
 

_____________________________________________________________________________________________________________

 

is there any past history of alcohol, drug or legal difficulties?     no  □    yes  □   

in what areas does the applicant require specialized training?  __________________________________________________ 

have you or any member of your immediate family been involved in any form of legal action  

against any school, public or private, and if so, what was the disposition of that case?
yes □  No  □

 

___________________________________________________________________________________________________

Text Box: Providing a unique learning environment customized to serving the needs of every student regardless of ability, race, color, creed or religious beliefs. Text Box: __________________________________________________ signature of applicant/parent                                                                      Text Box: i certify that all information in this application is true and complete to the best of my knowledge.