12611 N. Wilson St. Mead, WA 99021 PO Box 9233 Spokane, WA 99209 (509) 362-3418 firstname.lastname@example.org
Today’s Date: _________________ Referred by: _________________________________
Please circle the level your child will be entering: K Lower elementary upper elementary Jr H.
Student Information Full name: ___________________________________ Nickname: _______________________ Gender: _______ Date of Birth: _____________ SS#: _______________ Race: ___________________________ (CLCA does not discriminate on race, color, national and/or ethnic origin, or disability in admissions, consulting and/or hiring practices.) Mother’s Name: __________________________________________ SS#: _______________________ Address: ______________________________________________________________________ Email: ____________________________________________ Cell phone: ______________________ Work phone: ________________________________ Occupation: _____________________________________________ Job title: ______________________________________________
Father’s Name: _____________________________________________ SS#: _______________ Home address (if not living in the home): ____________________________________________ Cell phone: ________________ Work phone: ________________ Occupation: ___________________________ Job title: ______________________________ Marital status of parents: married _____ divorced _____ separated _____ Single ____ If divorced or separated who has legal custody of the student? ___________________________ Sibling information: Please list names and ages of all siblings: ______________________________ ___________________________ _____________________________
Does the family attend church regularly? ______ Religious beliefs: ______________________ Have you been involved in a private school before? ____________________________________ How did you hear about Can Learn Christian Academy? ________________________________ Why do you want your child to attend CLCA? _______________________________________________________________
Is he/s adopted? ______ If yes: WA state, International? (Country) ________________________________________ At what age? _________________ At what age did he/s come to your home? _________________________________ Does child have any diagnosis or labels? ____________________________________________________________________
_______________________________________________________________________________________________________________ Does child have any learning and/or attention struggles? ___________________________________________________
Does child have any emotional and/or social struggles? _____________________________________________________ Does child have any mental illness? __________________________________________________________________________ Is he/s hyperactive? _________ hypervigilant? ________ oppositional? ______________ As an infant did child spend much time on the floor (tummy time)? _____ yes ____ No Roughly how much time a day? _______________________________________________________________________________ How much time did they spend in walkers, saucers or lying on his/her back? ______________________________ Did you use an infant swing or rocking chair? ____Yes ___ No How old was child when he/s started rolling over? ______________ Did child belly crawl? ____ Yes ___ No if so, more or less than two months? ________ Did child creep (hands and knees)? ___ Yes ___ No if so, about how many months? ________ How old was child when he/s started walking? ________________ Any chronic medical conditions? ___________________________________________________ Does child need medication during the school day? ____________________________________ Has child had a comprehensive vision and/or hearing exam, other than at school? ____________ When and results? _______________________________________________________________________________________ If yes, may we have a copy? _______ What are his/her talents and/or interests? ___________________________________________________________________
What are his/her academic strengths? _______________________________________________________________________
What are his/her weak subjects? ____________________________________________________________________________
List FOUR POSITIVE qualities about your child: _____________________________________ ________________________________ _____________________________________ _________________________________ What is his/her attitude towards school and learning? ______________________________________________________
_________________________________________________________________________________________________________________ Please provide a copy of any written reports your child may have such as: Psychological _____ Speech ____ Hearing _____ Vision _____ Physical Therapy _____ Occupational Therapy _____ Brain Mapping _____ (IEP’s will be in school recorders) Does child prefer his/her left, right, or both? ___________ Which does he/s use most? _______
References: Please list four people who know your child well; including the most recent teacher AND principal. Many children ‘act’ differently in different environments. A negative reference does not mean we won’t accept him/her into the academy it just shows us how to help your child more. References WILL be contacted! Name Phone email Relationship ___________________________________________________________________________________________________________________
School Information and Background Please list ALL previous schools, grade & city/state and reason for leaving: __________________________________________________________________________________________________________________
Behavior & Discipline Information Please share information concerning your child’s behavior pattern. Don’t panic most of our students have been kicked out of more than one school and/or program. To better understand your child, we must ask some personal questions. Please be honest; we’re not judging you as a parent or your parenting skills but rather to know how to better serve both you & your child. We would like to honestly know the situation and reasons. Misrepresentation or withholding information may jeopardize your child’s enrollment.
Is your child currently in counseling? ____ _______ With whom? _______________________________________________ Phone # ____________________ we will call to talk to counselor before admissions allowed.
Has your child ever received disciplinary actions at school? Yes No School suspension? Yes No Asked to withdraw by school? Yes No Expelled? Yes No Please explain any ‘yes’ answers: ______________________________________________________________________________
__________________________________________________________________________________________________________________ Has child witnessed or been victimized by prolong physical, mental, emotional, verbal, sexual abuse and/or neglect? Yes No Please explain: _____________________________________________________________
_________________________________________________________________________________________________________________ Is your child aggressive and/or violent? Yes No What are his/her triggers? _____________________________________________________________________________________ Is child self-abusive (injure, harm or put self in dangerous situations) Yes No Please explain: ________________________________________________________________________________________________
_________________________________________________________________________________________________________________ Does child have a history of making false allegations? Yes No Please explain: ________________________________________________________________________________________________
Is he/s verbally abusive…at home? Yes No at school? Yes No Both? Yes No Is child physically abusive…at home? Yes No at school? Yes No Both? Yes No Whom does he/s usually target (go after)? __________________________________________________________________
Does child have a juvenile arrest record? _____________ Has child been in a Crisis Intervention Program (CRC, residential treatment center (RTC), or Rehab? Yes No Please explain: ___________________________________________________ What is the most challenging thing about parenting your child? ___________________________________________
First year parents are REQUIRED to participate in monthly parent support-training meeting (held after the monthly pot luck) as part of your child attending the academy. Are you ready to make a commitment to attend specialized parenting techniques that REALLY WORK? Yes ___ No ___
Release to take my child’s picture: I, ____________________________________, give my permission for my child, ________________________________, picture to be taken. These pictures may be used in the student’s file, website/Facebook and/or school brochure.
Permission for AVE (neuro-technology) I, ________________________________, give my permission for my child, _______________ ____________________________, to participate in the AVE program. 7 Signature: ____________________________ Date: _________________________________
Please tell us who MAY NOT pick your child up from school. We understand cars break down, you become ill, etc. In those cases, if someone different then listed here needs to pick your child up please call/text to let us know & we WILL check their picture ID before releasing your child to them.
Who IS ABLE to pick your child up? Name Relationship Contact # __________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________ Who IS NOT ABLE to pick your child up? If you have a restraining order against someone we need a copy AND recent picture of that person. We DO NOT release any information about a child over the phone/email, etc. Name Relationship Contact # _________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________ Note: Our first priority is the physical, mental and emotional safety of all students and staff. We have the right to refuse admission to or expel any child we feel would jeopardize the physical, mental and/or emotional safety & well-being of that child, other students and/or staff members.
Please read the financial information page before signing.
I, the undersigned, have read, understand and agree to abide by the tuition schedule and school policies. I also understand there is an early withdrawal penalty if I withdrawal my child before the end of the school year (mid-August). Parent/guardian Signature: _______________________________________ Date: _____________________