Preliminary Application of Interest

Please fill out the form below

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?*
- Yes
- No
Name of Diagnosing Physician*
Diagnosis*
Is your child has attended school?*
- Yes
- No
Name of School*
Dates attended*
Address*
Contact Person*
Phone Number*
Classroom Ratio*
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*
- Married
- Separated
- Divorced
Child Lives With*
- 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?*
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?*
Please comment on your child’s nutritional needs (dietary restrictions, special diets).*
Please describe any medical or physical concerns/ needs, including medications prescribed.*
How did you hear about Imagine Academy?*
In order to place a child at Imagine Academy, you are required to obtain legal representation. Do you have legal representation?*
- 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.

Preliminary Application of Interest

Step 1 of 4 - Child Information