Easterseals Academy Application

Applicant Information
Student Name *

First Name Last Name Suffix
Preferred Name *

First Name Last Name Suffix
Address *

Street Address

Street Address Line 2

City State

Zip Code
Student Date of Birth *

Month Day Year
Local School District of Residence *
Gender *
Student Ethnicity *
Student Race *
Primary Language Spoken at Home *
Birth City *
Birth State *
Birth Country *
How did you hear about us? *

Current & Previous School
School Name *
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State

Zip Code
From Date *

Month Day Year
To Date *

Month Day Year
Grade Completed *
Funding Source *
Matrix Score *
Primary Disability *
Secondary Disability *
Therapeutic services your child currently receives *
Is there a Court Order barring either parent from removing the student from school? *
Do parents have shared (or joint) parental rights and responsibilities? *
Does either parent have final decision-making authority regarding educational decisions for the student? *
Is there a Temporary Restraining Order, Permanent Restraining Order, Order of No Contact or other Court Order that restricts or impacts access to the student by anyone, including a parent? *
Are you interested in receiving information about our before/after care? *
Are you interested in receiving information about our therapy services? *
Please inform the school of any other vital information you think we may need to know in regards to your child *

Student Records Request Authorization

This form is to be used by the eligible parent/legal guardian or eligible student (age 18) to request the release of student information. Please note that the previous school from which the records will be requested may also require you to sign an authorization form.

As the parent or legal guardian, I hereby authorize Easterseals Academy to submit a student records request to the school listed below, in order to obtain educational records (if necessary). This authorization may be revoked at any time by providing a written/signed statement to Easterseals Academy.
School Name *
City/State *

Street Address

Street Address Line 2

City State
Parent/Guardian Name *

First Name Last Name Suffix
Parent/Guardian Name Signature *

Clear

Household Information
Household 1: First Parent/Guardian *

Prefix First Name Middle Name Last Name Suffix
Household 1: Home Phone Number
Please enter a valid phone number.
Household 1: Cell Phone Number *
Please enter a valid phone number.
Household 1: Email *
example@example.com
Household 1: Email 2
example@example.com
Household 1: Address *

Street Address

Street Address Line 2

City State

Zip Code
Household 1: Relationship to Applicant *
Household 2 information required if you responded “Yes” to this question.
Household 1: Custodial Rights *
Household 2 information required if you responded “Yes” to this question.
Household 1: Martial Status *
Household 2 information required if you responded “Yes” to this question.
Household 1: Does the applicant have a parent / guardian that lives at another address? *
Household 2 information required if you responded “Yes” to this question.
Second Parent/Guardian
(Leave blank if not applicable)
Household 2: First Parent/Guardian

Prefix First Name Middle Name Last Name Suffix
Household 2: Home Phone Number
Please enter a valid phone number.
Household 2: Cell Phone Number
Please enter a valid phone number.
Household 2: Email
example@example.com
Household 2: Email 2
example@example.com
Household 2: Address

Street Address

Street Address Line 2

City State

Zip Code
Household 2: Relationship to Applicant
Household 2 information required if you responded “Yes” to this question.
Household 2: Custodial Rights
Household 2 information required if you responded “Yes” to this question.
Household 2: Martial Status
Household 2 information required if you responded “Yes” to this question.
Household 2: Receive Correspondence
Household 2 information required if you responded “Yes” to this question.
Household 2: Does the applicant have a parent / guardian that lives at another address?
Household 2 information required if you responded “Yes” to this question.

Documentation
Birth Certificate

Cancel of
Current Immunization Records

Cancel of
Scholarship/Payment Verification

Cancel of
Most Recent IEP/FBA/Educational Records

Cancel of
My signature below affirms that all of the information contained in this application is correct, complete, and honestly presented. I understand that withholding or misrepresenting information in this application may jeopardize my child's admission.
Signature *

Clear
Name *

First Name Last Name Suffix
Date *

Month Day Year
Please verify that you are human *
Should be Empty:

Second Parent/Guardian (Leave blank if not applicable)

Documentation

Second Parent/Guardian
(Leave blank if not applicable)