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DS App

This document is an application for admission to the New Horizons School & Learning Center. It requests basic student information such as name, date of birth, address, grade, medical conditions, and history of behavioral issues. Parents are asked to provide contact information and sign to acknowledge that withholding pertinent medical information could jeopardize the student's well-being and the school's ability to address any issues. The document also provides financial and contact information for the school.

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matthew_hardwic6684
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55 views

DS App

This document is an application for admission to the New Horizons School & Learning Center. It requests basic student information such as name, date of birth, address, grade, medical conditions, and history of behavioral issues. Parents are asked to provide contact information and sign to acknowledge that withholding pertinent medical information could jeopardize the student's well-being and the school's ability to address any issues. The document also provides financial and contact information for the school.

Uploaded by

matthew_hardwic6684
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
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NEW HORIZON SCHOOL

& LEARNING CENTER


Day School Application
Date of Admission: School / District: CSIS #

Students Name
Last First Middle

Soc Sec# Address

Sex: M ( ) F ( ) Date of Birth


City

Current Grade
ZIP

Home Phone Parent/Guardian Address, if different Home phone Parent/Guardian Address, if different Home phone Student resides with Mother (

Student: Cell # Occupation Cell Phone Occupation Cell Phone ) Father ( ) Other ( )

E-Mail Wk # E-mail Wk # E-mail

List any medical conditions significant to your child's well being: Is your child currently receiving any medication? Yes ( ) No ( ) Doctor prescribing: Name of medications: Taken during school time? Yes ( ) No ( )

Is there any history of behavioral difficulty, in relationship to family, peers, or an academic setting? If so, has any evaluation or treatment been conducted regarding these problems? (Use additional page if needed.)
If you would like to make any other statement regarding your child, please feel free to do so on a separate sheet of paper and enclose it with this application. If your child has experienced either organically or emotionally based problems which have necessitated the use of medication or therapeutic intervention, it is of the utmost importance that this be indicated at the time of application in order that we may more effectively plan for the best way of addressing these needs. Withholding such information can only jeopardize your child's well being and hinder the school's ability to handle problems should they arise. Information pertinent to your child's application will be held in strictest confidence. Financial correspondence should be sent to: Name Address City State ZIP When we receive your completed application and copies of assessments, IEPs, etc., you will be sent a letter of acceptance or denial. If accepted, a contract, as well as other pertinent information will be sent. If you have any questions, contact Karen by leaving a voice mail message: 707-579-3723 x 1 Phone

Parent or Guardians Signature

Date

rev: 6-09 ks

827 Third Street Santa Rosa CA 95404 Tel: 707.579.3723 Fax: 707.579.8760 www.newhorizonschool.info

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