Academy at the Farm Enrollment Application Fall 2008-2009

Parents/Guardians Name ________________________________________________

Address ______________________________________________________________

City, State, Zip _________________________________________________________

Phone ( ) Cell_________________

Date of Application ____________

Student's Name (please print separate form for each child)_____________

Date of Birth Grade Entering August 2007_____________

Current Elementary School, Preschool or Child Care Center__________________________________

*Has your child ever been referred for academic testing by school personnel, private counselor, and/or doctor?____________________________________________________________________

*Has your child ever been diagnosed with a learning disability?_________________________

*Does your child have a 504 plan? _______________________________________

*Has your child ever been staffed into an ESE program? ______________________

*Does your child have an AIP (Academic Intervention Plan)?_____

If yes, in which area(s): Reading _____Writing _____Math Science_______

*Is your child currently enrolled in any of the following programs?
*Occupational Therapy_______ Physical Therapy Speech Therapy_______

Documentation must be provided for any "*" questioned answered "yes"

These questions are important to your child's potential placement and success at the Academy at the Farm. Failure to answer questions completely and provide documentation may result in your child's application and/or acceptance being denied or revoked.Siblings (name and grade) attending the Academy at the Farm OR are applying at the same time.

Parent Signature which verifies the above information is true and that your residence is located in either Pasco or Hillsbourgh Counties or your child has been officially accepted by one of these counties as a "transfer" student.

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Signature and Date