Application

Student’s Name: _________________________________DOB: ___________ Grade:                     

Sending School District: ___________________________Date                                                     

(Check one): IEP:______ 504 Plan: ________Other: _________ None:                                          

Data Page

Student Information:

Home Address:                                                                                                                         

( # Street)

(City – Town)( State ) (Zip )

Home Phone #: (            )                                                                                                          

Place of Employment:                                                                                                               

Work Phone #: (            )                                                     Ext                                                

Health Information

Physician                                                                            Telephone                                      

Current Mental Health Therapist                                            Telephone                                      

Allergies                                                Medications                                                                  

Health Insurance                                                                                                                       

Name of subscriber (usually the mother or father)                                                             

Policy #                                                                                                                                   

Parent(s)/Guardian(s) Information:

(1) Name:                                                                      Relationship:                                        

Place of Employment:                                                                                                               

Work Phone # :(            )                                               Cell Phone #:                                        

(2) Name:                                                                      Relationship:                                        

Place of Employment:                                                                                                               

Work Phone # :(            )                                               Cell Phone #:                                        

Alternate Emergency Contact:

Name:                                                                           Relationship:                                        

Work Phone # :(            )                                               Cell Phone #: