Application for Admission  

 

 

Name of Student / Applicant:  _________________________________________________________________________________________

 

Address:  ___________________________________________   City:  ___________________________  Zip:  _________________

 

Home Phone:   (         ) _________  - ____________   Work Phone:  (         ) _________  - ______________  

 

Mobile Phone:   (         ) _________  - ____________   Other Phone:  (         ) _________  - ______________  

 

Age:  _______________       Date of Birth:  _________________            Grade:  ___________________

 

Name of Parent(s) Legal Guardian(s):

 _________________________________________________ _________________________________________________

 

Name of School Last Attended:  ____________________________________________________________

 

Dates Attended:  from ____________ thru ____________ Last Grade Completed:  __________________

 

Reason for Leaving:  _______________________________________________________________________________________________

 

Does your child have an Individual Education Plan (IEP)?  Yes       No

 

Is it current: Yes       No

 

How Did You Hear About Casa Richard Academy?  _______________________________________________________________________

 

Signature of Parent / Guardian:  ______________________________________________________________  Date:  ______/______/______