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Giving
Home
About Us
Welcome
Meet the Staff
Our Advisory Board
Our Founders
Hear from Our Parents
Facilities
Careers
COVID-19 Plan of Care
Programs
Academics
Vocational Skill Training
Speech and Language Therapy
Occupational Therapy
Physical Therapy
Creative Arts Therapies
Typing
Student Life
Therapeutic Swim
Augmentative and Alternative Communication Training
Social Skills Training
Recreational Skill Building
Respite and After School Programs
Overnight and Field Trips
Family Partnerships
Post-21 Planning
Community Outreach
Elective Classes
Admission
Events
Upcoming Events
Past Events
Events Calendar
Media
Imagine is Social
Picture gallery
Giving
info@imagineacademy.org
718.376.8882
Preliminary Application of Interest
Please fill out the form below
Step 1 of 4 - Child Information
25%
School Year of Interest
*
Last Name
*
First Name
*
Middle Name
*
Date of Birth
*
Age
*
Gender
*
Male
Female
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Language/s Spoken at Home
*
Has your child received a label or a diagnosis of autism or a related disorder from a physician or other professional?
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Yes
No
Name of Diagnosing Physician
*
Diagnosis
*
Is your child has attended school?
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Yes
No
Name of School
*
Dates attended
*
Address
*
Contact Person
*
Phone Number
*
Classroom Ratio
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Please Describe the Educational Approach of This School
*
Please Attach a Photo of Your Child
*
Father/ Guardian Name
*
First
Last
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number of (Father/ Guardian)
*
Email of (Father/ Guardian)
*
Occupation
*
Employer
*
Work Phone
*
Mother/ Guardian Name
*
First
Last
Mother’s Maiden Name
*
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number of (Mother/ Guardian)
*
Email of (Mother/ Guardian)
*
Occupation
*
Employer
*
Work Phone
*
Parents Are
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Married
Separated
Divorced
Child Lives With
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Father
Mother
Other
Other
*
Siblings and Extended Family
*
Name
Age
Relationship
Current School/ Program
Has your child had a psychological or educational evaluation (by a school, privately, or by the Department of Education)? If so, please describe the date(s), circumstances, and outcomes of the evaluation(s)
*
Yes
No
Siblings and Extended Family
*
Date(s)
Circumstances
Outcomes of the Evaluation(s)
Please upload any relevant documents (e.g., IEP, current school progress reports, evaluation reports, etc.)
*
Does Your Child Receive Services (i.e., OT, PT, Speech and Language, Psychologist/ Counseling)? If so, Please Provide the Type of Service, Frequency and Duration.
*
Yes
No
Type of Service
*
Frequency
*
Duration
*
What would you like us to know about your child?
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What communication skills does your child currently have? (How does your child communicate: vocalizations, signs, pictures/PECS, communication device). Describe how he/she gets his/her needs met.
*
What behavior challenges, if any, does your child exhibit (e.g., aggression, stereotypical, self-injurious, etc.)? What triggers these behaviors?
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Please comment on your child’s nutritional needs (dietary restrictions, special diets).
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Please describe any medical or physical concerns/ needs, including medications prescribed.
*
How did you hear about Imagine Academy?
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In order to place a child at Imagine Academy, you are required to obtain legal representation. Do you have legal representation?
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Yes
No
Legal Representation
*
NOTICE OF NONDISCRIMINATORY POLICY AS TO STUDENTS
Imagine Academy admits students of any race, color and national or ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at our school and does not discriminate on the basis of race, color and national or ethnic origin in administration of our educational policies, admissions policies, scholarship and loan programs and athletic and other school administered programs.
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