Application For Enrollment Student's Full Name * First Name Last Name Preferred Name First Name Last Name Please check if there are NO changes from the previous school year * Male Race * Applying for School Year * Grade * Date of Birth * MM DD YYYY Student's Cell Phone (###) ### #### Student Email Please check if there are NO changes from the previous school year. Mother's Name * First Name Last Name Mother's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mother's Home Phone (###) ### #### Mother's Cell Phone * (###) ### #### Mother's Home Email * Mother's Work Email Employer * Occupation/Title * Work Address Address 1 Address 2 City State/Province Zip/Postal Code Country Father's Name * First Name Last Name Father's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Cell Phone * (###) ### #### Home Email * Work Email Employer * Occupation/Title * Work Address Address 1 Address 2 City State/Province Zip/Postal Code Country Are parent's divorced? * Yes No If yes, who is the student's legal guardian? Student resides with To whom should financial correspondence be sent? * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * CC Email Maternal Grandparent(s) Name * Maternal Grandparent(s) Address Address 1 Address 2 City State/Province Zip/Postal Code Country Paternal Grandparent(s) Name * Paternal Grandparent(s) Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Sibling 1 Name First Name Last Name Sibling 1 Age Sibling 1 School/Current Grade Sibling 2 Name First Name Last Name Sibling 2 Age Sibling 2 School/Current Grade Sibling 3 Name First Name Last Name Sibling 3 Age Sibling 3 School/Current Grade Sibling 4 Name First Name Last Name Sibling 4 Age Sibling 4 School/Current Grade School Previously Attended Grades Attended Reason For Leaving What was your child's age when he/she entered first grade? * Has the student repeated any grades? * Yes No If yes, which grade? Is the student currently receiving tutoring? * Yes No Does the student have any physical disabilities, allergies, or regular medications? * Has the child had excessive or extended absences from school? If yes, explain. * Pediatrician's Name * First Name Last Name Pediatrician's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pediatrician's Phone * (###) ### #### Has the student been diagnosed with a specific language based learning disability by a qualified Psychologist? * Yes No Psychologist Name First Name Last Name Psychologist Phone (###) ### #### Psychologist Address Address 1 Address 2 City State/Province Zip/Postal Code Country Full Report: Attached Being Forwarded Has the student had a cognitive assessment (IQ test)? Yes No Type: WISC Stanford-Binet Other Report: Attached Being Forwarded Other testing notes: Check the services that have been recommended for your child. Tutoring Counseling Speech/Languages Therapy Occupational Therapy Medication Please provide the following information about services your child is receiving or has received in the past.Please attach a copy of all reports and evaluations.ProviderDates of Service Results/DiagnosisTutoringCounselingSpeech/Language TherapyOccupational TherapySchool ServicesOtherDoes your child have any special abilities, talents or hobbies? Please include any competitions or awards. * Who referred you Bright Academy? * State your primary concern * When was this difficulty first noticed? * How did your child's school describe the difficulty? * What factors do you think might have contributed to the difficulty? * Does your child feel he/she has a problem? (If so, describe these feelings.) * * The information provided on this application is correct and complete to the best of my/own knowledge. Signature of Mother/Guardian * Date * MM DD YYYY Signature of Father/Guardian * Date * MM DD YYYY TERMS AND CONDITIONSApplications are made to the governing authority of Bright Academy which reserves the right to accept or reject any application.Bright Academy admits students of any race, color, or national and ethnic origin to all rights, privileges, programs and activities generally accorded or made available to students of the school. Bright Academy does not discriminate on the basis of race, color, or national and ethnic origin in administration of its educational policies.School policies are subject to change. Information on current policies will be made available at parent orientation meetings prior to enrollment.Applicants agree to abide by all school policies, rules and regulations, including provisions for dress codes and discipline.Applicants agree that their students will receive instruction in the Christian Faith and understand that the school will endeavor to be guided by a Christian worldview in all of its programs and activities.The school has policies designed to meet a reasonable standard of care for students who become ill or have an emergency situation at school. Parents are required to sign a medical release form each year allowing emergency medical care to be obtained in the case parents cannot be reached. Parents understand the school is not an insurer of student health. The school procedures governing health care plans and the storage and administration of medications are available from the Administration.The school’s Tuition & Fee Schedule provides information about financial terms and obligations. It is updated annually. Students are enrolled for the entire year and the parent or guardian is responsible for the annual tuition payment upon accepting enrollment.PARENT OR GUARDIAN AGREEMENTI hereby certify that I have read this Student Application Form, including the Terms and Conditions Section. I do agree to comply with the terms and conditions stated therein and furthermore accept the conditions and requirements of all other official policies and procedures of Bright Academy, including the payment of all fees and charges according to the published schedule of the school. This application cannot be processed until the application fee is paid in full and the application is signed by the parents or guardian of the applicant.Parent/Guardian Signature * Date * MM DD YYYY Parent Signature * Date * MM DD YYYY Thank you!
