Application Form - Wellspring Academy

GENERAL INFORMATION

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Guardian Email Address

Student Social Security Number

School last attended:

EMERGENCY CONTACT

First Name of Emergency Contact

Last Name of Emergency Contact

Phone/Mobile

Contact's Relation to you:

Applicant's Doctor

Doctor's Phone Number

Hospital Preference

PARENT/GUARDIAN AND FAMILY INFORMATION

Please fill out the following information for the father.

Father's First Name

Father's Last Name

Father's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Father's Employer's Name

Father's Job Title

Father's Occupation

Father's Home/Mobile Phone Number

Father's Work Phone Number

Father's Email

Lives with Student

Yes

No

Receives Mail

Yes

No

Receives Bill

Yes

No

PARENT/GUARDIAN AND FAMILY INFORMATION

Please fill out the following information for the mother.

Mother's First Name

Mother's Last Name

Mother's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Mother's Employer's Name

Mother's Job Title

Mother's Occupation

Mother's Home/Mobile Phone Number

Mother's Work Phone Number

Mother's Email

Lives with Student

Yes

No

Receives Mail

Yes

No

Receives Bill

Yes

No

If parents are separated or divorced, who has legal custody?

Mother

Father

In the event of sole primary custody, the school requires copies of the custodial legal documents to be provided at the time of application.

STUDENT APPLICATION

Please list names, birthdays, ages, grades and schools attending (including preschoolers) of all school aged children in your family

CHURCH AFFILIATION

Do you have a church affiliation? What is the name?

How long have you attended this church?

Does the family attend church together regularly? Please explain.

PARENT QUESTIONNAIRE

How did you hear about Wellspring Academy?

Considering the goals for your student, why would you like your student(s) to attend Wellspring?

Has the student ever been referred to a resource teacher? If yes, please provide date and reasons for referral.

Has the student ever had modifications made in the classroom?

Has the student ever been administered psychological, behavioral, or academic testing to determine if he/she is gifted, has a learning disability, ADD, ADHD, behavioral, neurological, sensory, or emotional disorder? If yes, please provide dates, test results, evaluations, IEP reports, etc. This information is not routinely part of the cumulative folders and must be requested by the parent/guardian from the resource teacher or school counselor.

Is the student presently taking any medication for medical or learning problems? If yes, please provide kind of medication, dosage, and frequency. Please provide a copy of a medical evaluation, which must be within the last twelve months.

Does your child have any allergies? If yes, please list all

Does your student have any health problems?

Premature birth (Y/N): If yes, what was the term?

Does your student have normal or corrected vision?

Normal

Corrected

Does your student have normal hearing?

Yes

No

Has your student ever been recommended for tutoring or remedial instruction? If yes, please provide dates and areas of remediation along with written evaluations.

Has the student ever repeated a grade? If yes, which grade and please explain

Has the student ever been suspended or dismissed from school? If yes, which grade and please explain

Has your child had disciplinary difficulty in his or her previous school? If yes, which grade and please explain

Is your child a ward of the court?

Yes

No

Has your child been under the jurisdiction of the court?

Yes

No

Has your child committed a felony?

Yes

No

Is there any additional information that Wellspring should be aware of when considering this student for enrollment?

What activities or responsibilities are you and your student(s) involved in at your church?

Please describe how prayer, Bible reading and discussion about God happen in your home.

Please give a brief statement summarizing your beliefs as it relates to: Jesus Christ

Please give a brief statement summarizing your beliefs as it relates to: The Bible

By submitting this application we certify that the above answers are true and are made with no reservations:

Upon acceptance to Wellspring Academy, two conditions are required to secure that acceptance in a classroom:

● A $250.00 registration deposit must be paid to Wellspring Academy and is non-refundable.

● Families must purchase an Alveary membership for $250 and provide proof of purchase.