Student Application Application Fee: $50 Application Date K-2ND APPLICANTS ONLY: How would you like to pay the tuition payment of $7950? One payment 12 payments of $658.33 PREK-4 APPLICANTS ONLY: How would you like to pay the tuition payment of $6900? One payment 12 monthly payments Student's Full Name (First, Middle, Last) Preferred Name Complete Address Phone Email Age Sex Male Female Birthday Birthplace (City, State, Country) Last school attended Last Grade Completed Last school address Father/ Guardian Legal Name: Address: Employer: Position: Cell Phone Mother/ Guardian Legal Name: Address: (if different from father) Employer: Position: Cell Phone Marital Status: Married Divorced Remarried Separated Divorced Single Children in family other than applicant: Child Name and Age Church attending Pastor Address Phone Father is a Christian Yes No Mother is a Christian Yes No Family has daily devotionals Yes No Family says grace at meals Yes No Child has made a profession of faith Yes No Profession of Faith Made at What Church? Date of Profession of Faith Child has been Baptized by Immersion? Yes No Where was Baptistm? What are your reasons for wanting to enroll at Lakes Academy? Briefly describe your child. Is there anything that you think you should know about your child in order to teach or discipline him/her effectively? Does your child have any physical, mental, or emotional handicaps that may affect his or her activities or progress that should be known? Has a child care provider or teacher ever recommended your child for academic testing for learning disabilities or ADD/ADHD? Explain Does your child currently have an IEP? Yes No Does your child currently have a 504? Yes No Family Physician/ Pediatrician Phone Does your child have any physical disabilities or allergies? Explain. Are there any diagnosed learning disabilities (dyslexia, speech, ADD, ADHD, etc) that require special treatment and/or programs? Is your child on any medication? If so, please list medication and explain usage. We hereby certify that the above answers are true and made with no reservations beyond those in the explanations. Yes Father signature and date Mother signature and date Signature and date Child’s latest report card or grade progress report Child’s Birth Certificate Child’s Immunization Record from Pediatricians office Send
