Application

APPLICATION FOR ADMISSION

Applicant Information:

Name Preferred Name___________Grade____

Last First Middle

Current Address Home Phone______

Street City Zip

Birth Date: Age: US Citizen: Yes No__ SS#_________________

Family Information:

Father Mother

(Mr. Dr.)________________________(Mrs. Ms. Dr.)____________________________

_____________________________ Home Address _____________________________

_____________________________ City, State, Zip______________________________

_____________________________ E-mail Address _____________________________

(___)_______________________ Home Phone ( )_________________________

( ) Cell Phone ( ) _

____________________________ Occupation/Title ____________________________

____________________________ Employer ____________________________

___________________________Employer Address_____________________________

(___)___________________ Business Phone (___)_________________________

In case of divorce or separation, please respond to the following questions:

Applicant lives with: father____ mother_____ other_____________________________

Legal custody: joint ____ father_____ mother_____ other________________________

Correspondence should be sent to: father____ mother____ other____

If remarried, name of stepfather/stepmother ________________________________

School information:

Current school________________________________Present grade________

Address of school _________________________________________________________

Street City State Zip Phone #

Please list all previous schools attended prior to current school listed above:

School Address Phone Number

________________________________________________________________________

How long has the applicant attended his/her current school? ________________

Parent Perspective: Feel free to attach additional sheets if necessary.

Share with us your perception of your child’s strengths, relative weaknesses, talents, extracurricular interests, etc.

_______________________________________________________________________

How might Walker Academy be a good match for your child as well as your family?

_______________________________________________________________________

________________________________________________________________________

Has applicant been dismissed from, suspended from, or not allowed to return to any school? _____yes _____no If yes, please explain______________________________

_______________________________________________________________________

Has applicant been put on academic/disciplinary probation at any school? ___yes ___no

If yes, please explain: _____________________________________________________

_______________________________________________________________________

Student’s primary language_________________ Language spoken at home___________

Is there anything else we need to know about this student’s education background or family circumstances that may impact our ability to serve him/her? Please explain _____

________________________________________________________________________

Please list all prescription medications your child takes (name and dosage) on a daily basis:

________________________________________________________________________

Please list any allergies that your child has: ____________________________________

Siblings: Please list any other children living in the home.

Name________________________Age_____School attending_____________________

Name _______________________Age ____ School attending _____________________

Grandparents:

Maternal: _______________________________________________________________

Name Address

Paternal: _______________________________________________________________

Name Address

Non-Parental Emergency Contact: (Every attempt will be made to contact a parent first in the case of emergency)

Name_________________________________________Relationship to Student_______

Home Phone___________________ Work Phone________________ Cell____________

Emergency Information:

Physician’s Name_______________________________Phone____________________

Hospital Preference_______________________________________________________

Educational Testing: Please indicate if the applicant has been tested or evaluated for a learning disability or attention deficit disorder. Please include a copy of these results with your application.

______Yes ______No Date of last test ______________ Other information you would like to provide:

_______________________________________________________________________

Please note: It is the parents’ responsibility to provide any special needs files for the student prior to acceptance. Failure to do so may result in the student being denied acceptance. If it is discovered, after the student has been admitted, that records were withheld, the student may be asked to withdraw.

Student Essay: Please HAND WRITE an essay about yourself. We want to learn about YOU. Please tell us about any special talents that you have, unusual interests, your ambitions, your family, or a significant event in your life.

________________________________________________________________________

HONOR CODE: Having an honor code is important to the life of a student. Throughout your schooling, expectations are set for you to meet the obligations of doing your own work, being honest and truthful, to be responsible for yourself, and to do the right thing. Please write a brief paragraph explaining your understanding and commitment to following an honor code.

_______________________________________________________________________

Student Signature_____________________________________Date________________

Parent Involvement: We want you to be a part of the Academy family. Please list any skills or talents that you would be willing to volunteer to the school.

_______________________________________________________________________

Parent Signature ____________________________________Date__________________