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» Admission Application
Student Information
Student Information
First Name
Middle Name
Last Name
Name Used
Sex
Male
Female
Date Of Birth
General Information
Street Address
City
State
Zip Code
Home Phone
Father's/Guardian's Name
Occupation
Father's/Guardian's Address (if different from above)
Place Of Employment Name
City
State
Zip Code
Home Phone
Mobile Phone
Work Phone
Email
Mother's/Guardian's Name
Occupation
Mother's/Guardian's Address (if different from above)
Place Of Employment Name
Street Address
City
State
Zip Code
Home Phone
Mobile Phone
Work Phone
Email
How did you hear about Rivers Bend Academy / Step by Step?
Are Both Parents
Living
Divorced
Separated
Where does your child attend school now?
Grade Level
Reason for leaving?
Names and ages of other children in family and name of the schools currently attending:
1.Other name
Age
School
2.Other name
Age
School
3.Other name
Age
School
Medical and Therapeutic Information
Child's Pediatrician Name
Phone
Address
Has your child been seen by a developmental or clinic psychologist?
Yes
No
If yes, please answer the following:
Name of Professional
Date Of Last Visit
Has your child been seen by a developmental Pediatrician?
Yes
No
If yes, please answer the following:
Name of Professional
Date Of Last Visit
Has your child been seen by a developmental Psychiatrist?
Yes
No
If yes, please answer the following:
Name of Professional
Date Of Last Visit
Insurance
Group#
Is your child receiving any medical intervention?
Yes
No
If yes, please indicate the medicine and dosage amount:
Is your child on a special diet?
Yes
No
If yes, please describe the diet:
Does your child have Allergies?
Yes
No
If yes, please describe the allergies:
Please indicate all therapeutic or educational interventions that your child is receiving now (Including names of provider and frequency) :
Parent Questionnaire
What are you looking for in a facility based program for your child?
Have you had negative experiences with programs where you child has been enrolled?
Interaction/Communication
How does your child communicate with you/adults? (Form of communication)
How does your child communicate with peers/siblings? (Form of communication)
When does your child communicate with you and for what purpose?
Please provide any additional insight into the way your child communicates:
Social & Emotional
How would you describe your child?
Usually Very Active
Active sometimes, but can play quietly
Usually not active,has to be prompted
Usually happy
Can be moody
Demands excessive attention
Agressive towards self or others
Short attentiion span
Lacks confidence in self
Enjoys playing with others
Prefers motor activities
Prefers sit-down activities
Define the above marked items:
Does your child engage in problem behaviors?
Yes
No
If yes, please describe:
Under what conditions does the behavior occur?
What situations/interactions have been used in the past? (effective and not effective)
Is your child afraid of anything? Please describe:
Feel free to elaborate on any aspect of your child:
Skills & Interests
What kind of play or recreational activities does your child seem to enjoy most?
What are his/her favorite items?
Does your child enjoy
playing alone?
With younger children?
With similar aged children?
With adults?
With a group of children?
Please Describe:
Academic Information
Please describe the type of classroom setting your child was in:
Does your child enjoy art, and if so, what kinds of activities?
Does your child enjoy music, and if so, what kinds of activities?
During your first appointment with Rivers Bend Academy / Step by Step and if applicable, please provide work samples and progress reports from school, including: a raw writing sample, list of recent reading material, samples of math activities and/or a list of math curriculum topics recently covered.
Please also provide a brief written assessment of your child’s academic strengths and weaknesses as you perceive them, and a summary from your child’s current teacher.
Please include any IEP, testing from school systems, testing from private facilities, doctor’s recommendations, etc
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Initial
Digital Signature
Date
