All of the Following Information Must Be Filled out to Complete the Student S File

2017-2018 Application for Admission All of the following information must be filled out to complete the student’s file. APPLICANT

Full Name of Applicant: Gender (Click on Drop Down Menu) Applying for Grade Level: Proposed Starting Date: Address: City State Zip Code Phone # E-mail DOB Social Security #

Does your student have a current or expired IEP/504 Plan? Date of IEP/504 Plan:

PREVIOUS SCHOOL(S)

Name of School: Dates Attended: Phone # Fax # Reason for Leaving:

Name of School: Dates Attended: Phone # Fax # Reason for Leaving: Reason for applying to Humanex Academy: How did you hear about Humanex Academy:

PARENTS/GUARDIANS

Full Name of Father: Occupation: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: E-mail Address:

Full Name of Mother: Occupation: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: E-mail Address:

Full Name of Guardian: Occupation: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: E-mail Address:

1 Applicant Lives With: Person Financially Responsible for Tuition and Fees: Current Doctor’s Name: Phone # Current Psychologist Name: Phone #

STUDENT PROFILE **The information gathered in this section is for intake purposes only and does not determine admission to Humanex Academy.**

ACADEMIC INFORMATION 1. Has you child had any of the following accommodations in the past? IEP Assistive Technology Assignments 504 Plan Scribe to assist w/writing Allowed to stand and/or Extended time Reader to assist Pace Allowed to sketch Use of calculator w/reading Allowed a fidget object Use of a computer Oral quizzes/tests Project-based (stress ball)

2. In which areas has your student had the greatest success?  Math  Art/Creative  Retention  Science Projects (memory)  Physical  Executive  Reading Education Function  Writing  Comprehension  (organization &  Social Studies follow through)  3. In which areas has your student needed the most support/accommodations?  Math  Art/Creative  Retention  Science Projects (memory)  Physical  Executive  Reading Education Function  Writing  Comprehension  (organization &  Social Studies follow through)  4. Regarding schoolwork, please check all that apply to your student:  Comprehends  Needs to be able  Needs help verbal to getting  Instructions  clarify  Started  Comprehends instructions  Needs frequent written  Self-starter check  Instructions  Independent &  in’s  Needs confident  Needs constant instructions  Worker   written down  Stays on task attending/guiding  Needs  Makes in-class  Falls off task instructions  transitions  Struggles to  broken up easily transition

2  between  Distracted by  in class activities others   (visual/auditory)  5. Regarding homework please check all that apply to your student:  Comprehends   verbal  Independent &  Struggles to  Instructions confident transition  Comprehends  Worker  between activities written  Stays on task  Distracted by  Instructions  Makes task  Needs transitions  environment instructions  Easily  (visual/auditory)  written down  Needs help  Parent must  Needs getting read for instructions  Started  Student  broken up  Needs frequent  Parent must  Needs to be able check scribe for to  in’s  Student  clarify  Needs constant instructions  Homework is a   Self starter attending/guiding  problematic endeavor   Falls off task            BEHAVIORIAL INFORMATION   Is your student currently under the care of a mental health professional?  6. If yes, please provide contact information:   If No, are you open to pursuing such support?  7. Has your student been diagnosed with any of the following:  ADD  Asperger’s  Borderline  ADHD Syndrome Personality  (ASD)  Disorder  Addiction  Autism (HFA)  Chronic  AFS/AFE  Bi-polar Insomnia  Anxiety Disorder  Depression Disorder  Diabetes 3  Dyscalculia  LD- NOS  RAD  Dysgraphia  PDD  Other:  Dyslexia  PTSD 8. Has your student ever been suspended or expelled from another school?   If YES, please explain the cirmcumstances:  9. Has your student ever been hospitalized or spent time in a detention center for any mental or behavioral health reason?   If YES, please explain:  10. Has your student ever been charged with or convicted of a misdemeanor or felony?  IF YES, please explain:   MEDICAL INFORMATION 1. Does your student currently take any medication?  Please list:  2. Does your student take medication during the school day?  If Yes, please list name(s), dosage(s), time(s):  3. Does your student currently have any of the following needs:  Wears glasses/contact lenses  Wears hearing aid(s)  Uses a wheelchair, crutches, &/or cane  Other:  4. Does your student have any medical conditions or syndromes that would be helpful for us to know about?  Please list:  5. Does your student have up to date immunizations?  (please provide a card to the front office)  If No, Please explain:  6. Do you know your student’s complete medical background?  Please explain:  7. Is there any other medical information about your student that you would like to share with us?  (If Yes, please use a separate sheet of Paper)        SOCIAL INFORMATION  1. How would you rate your student’s social skills on a scale of 1-10. (1= lowest, 10= highest):  2. What areas of concern do you have for your student’s social skills?

4  Making friends  Staying out of   Allowing others  Keeping friends social  Drama to have  Picking positive  Making good  their views friends choices  Maintaining  Having diverse  (getting work self-esteem groups of done,  Recovering  friends  avoiding from set-  Reading social drugs/alcohol)  Backs cues  Being a leader  Growing into  Responding  Standing up for new positively to what is  interests  social cues  right    3. How does your student respond to instructions, structure, and authority? Check all that apply.   Easily w/ room  OK but needs  for firm  Rejects  Growth  Delivery direction until  Easily  OK but best  feels safe w/choices w/out too  Rejects  Easily w/written  many choices direction unless  written  Expectations  Needs expectations  Well but needs explanation  Takes direction  Needs written  encouragement guidance Not well and  Personally  Well and needs needs to  Avoids gentle  feel has a say   Approach  Not well but responsibility/ownership  Well when relaxes w/  Develops choices are  Support personality  Given  Rejects  conflicts w/  OK but needs authority direction support  4. How does your student respond to individual work?  5. How does your student respond to group work?    For the Student to complete. Please attach answers on a separate sheet of paper.   Why would you like to attend Humanex Academy?    How do you think Humanex Academy can help you?    What do you expect to contribute to Humanex Academy? 5    What do you expect to take away from Humanex Academy?   How do you plan to manage the self-paced challenges of the Humanex Academy program?               SCHOOL POLICY AGREEMENT  I/we, the undersigned, agree to comply with all school regulations and procedures as set forth in the school handbook.   ______ Signature of Parent or Guardian Date   ______ Signature of Parent or Guardian Date   ______ Signature of Student Date    FIELD TRIP PERMISSION   I give my permission for ______to attend field trips as a part of the Humanex Academy program. I agree to release and discharge Humanex Academy, its staff, teachers and employees, exercising reasonable care within their scope of employment, for liability growing out of personal injuries resulting or occurring during these activities, or in transit to and from said activities.   ______ Parent or Guardian’s Signature Date     PHOTOGRAPHY RELEASE  I give my permission for the student named on this application to be photographed. I understand that the images may be used for the yearbook, website, marketing, and/or public relations.   ______ Parent or Guardian’s Signature Date    BOOK RETURN AGREEMENT 6  Textbooks and other educational materials may be checked out to students at Humanex Academy during the school year.   We agree that any materials, books, CDs, videos, textbooks, or other educational materials which are checked out to the student listed below are his or her responsibility. If these items are not returned at the end of the school year, we agree to pay the replacement cost of these items. Any outstanding fees for books or other checked out materials must be paid before students can either reenrollment or before transcripts will be sent to other schools.    ______ Student’s Signature Date   ______ Parent/ Guardian’s Signature Date   HUMANEX ACADEMY’S MISSION STATEMENT   The mission of Humanex Academy is to provide a high quality, caring, and well-structured learning environment for students with unique academic, social, and/or emotional needs where they can develop the necessary skills to become productive citizens.   HUMANEX ACADEMY’S NON-DISCRIMINATION POLICY   Humanex Academy does not discriminate against any student because of race, creed, ethnic or national origin, gender, sexual orientation or religion.