Student Application

Student Photo

Photo

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A photo must be uploaded.

Student Information

First Name

Middle Name

Last Name

What grade are you applying for?

Does the applicant have any siblings enrolled?

Yes No

Enrollment Year

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Student History

Birth Date

Birth Place

Sex

Male Female

Race

Parent/Guardian Home Language

County of Residence

Describe Any Additional Health Problems or Medical Diagnosis

Please list all medications and dosages for your child

Contact Information

You need at least one contact marked as primary!

Add New

Last School Information

School Name

School Type

Public Private Charter School McKay Scholarship Home

Address Line 1

Address Line 2

City

State

Zip Code

Does your child have a primary diagnosis of Autism Spectrum Disorder?

Yes No

Does your child have an IEP?

Yes No

Name of ESE/IEP Programs from school district?

Signature

Please upload a copy of your child’s current IEP and any additional paperwork that will assist us in determining a placement for your child.

Diagnosis of ASD (Autism Spectrum Disorder) will be required

Parent/Legal Guardian

Date

11/21/2024

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