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) Choose One
Applying for Grade Level: Choose One
Address:
City
State
Phone #
E-mail
Social Security #
Proposed Starting Date:
Zip Code
DOB
Does your student have a current or expired IEP/504 Plan? Date of IEP/504 Plan:
PREVIOUS SCHOOL(S)
Name of School:
Phone #
Reason for Leaving:
Dates Attended:
Fax #
Name of School:
Phone #
Reason for Leaving:
Reason for applying to Humanex Academy:
How did you hear about Humanex Academy:
Dates Attended:
Fax #
PARENTS/GUARDIANS
Full Name of Father:
Address:
Home Phone:
E-mail Address:
City:
Work Phone:
State:
Cell Phone:
Occupation:
Zip Code:
Full Name of Mother:
Address:
Home Phone:
E-mail Address:
City:
Work Phone:
Occupation:
State:
Cell Phone:
Zip Code:
Occupation:
State:
Cell Phone:
Zip Code:
(Or)
Full Name of Guardian:
Address:
City:
Home Phone:
Work Phone:
E-mail Address:
Applicant Lives With:
Person Financially Responsible for Tuition and Fees:
Current Doctor’s Name:
Phone #
Current Psychologist Name:
Phone #
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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
Scribe to assist w/writing
504 Plan
Reader to assist
Extended time
w/reading
Use of calculator
Oral quizzes/tests
Use of a computer
Project-based
Assistive Technology
Assignments
2.
3.
4.
5.
Allowed to stand and/or
Pace
Allowed to sketch
Allowed a fidget object
(stress ball)
In which areas has your student had the greatest success?
Math
Social Studies
Science
Art/Creative Projects
Reading
Physical Education
Writing
Comprehension
Retention (memory)
Executive Function
(organization & follow through)
In which areas has your student needed the most support/accommodations?
Math
Social Studies
Science
Art/Creative Projects
Reading
Physical Education
Writing
Comprehension
Retention (memory)
Executive Function
(organization & follow through)
Regarding schoolwork, please check all that apply to your student:
Comprehends verbal
Self-starter
Instructions
Independent & confident
Comprehends written
Worker
Instructions
Stays on task
Needs instructions
Makes in-class
written down
transitions easily
Needs instructions
Needs help getting
broken up
Started
Needs to be able to
Needs frequent check
clarify instructions
in’s
Regarding homework please check all that apply to your student:
Comprehends verbal
Independent & confident
Instructions
Worker
Comprehends written
Stays on task
Instructions
Makes task transitions
Needs instructions
Easily
written down
Needs help getting
Needs instructions
Started
broken up
Needs frequent check
Needs to be able to
in’s
clarify instructions
Needs constant
Self starter
attending/guiding
Falls off task
2
Needs constant
attending/guiding
Falls off task
Struggles to transition
between activities
Distracted by others
in class
(visual/auditory)
Struggles to transition
between activities
Distracted by
environment
(visual/auditory)
Parent must read for
Student
Parent must scribe for
Student
Homework is a
problematic endeavor
BEHAVIORIAL INFORMATION
Is your student currently under the care of a mental health professional?
6.
Choose One If yes, please provide contact information:
If No, are you open to pursuing such support? Choose One
7.
8.
Has your student been diagnosed with any of the following:
ADD
Bi-polar Disorder
ADHD
Borderline Personality
Addiction
Disorder
AFS/AFE
Chronic Insomnia
Anxiety Disorder
Depression
Asperger’s Syndrome
Diabetes
(ASD)
Dyscalculia
Autism (HFA)
Dysgraphia
Dyslexia
LD- NOS
PDD
PTSD
RAD
Other:
Has your student ever been suspended or expelled from another school? Choose One
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?
Choose One
If YES, please explain:
10. Has your student ever been charged with or convicted of a misdemeanor or felony? Choose One
IF YES, please explain:
MEDICAL INFORMATION
1. Does your student currently take any medication? Choose One
Please list:
2.
Does your student take medication during the school day? Choose One
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? Choose One
Please list:
5.
Does your student have up to date immunizations? Choose One
(please provide a card to the front office)
If No, Please explain:
6.
Do you know your student’s complete medical background? Choose One
Please explain:
7.
Is there any other medical information about your student that you would like to share with us? Choose One
(If Yes, please use a separate sheet of Paper)
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SOCIAL INFORMATION
1. How would you rate your student’s social skills on a scale of 1-10. (1= lowest, 10= highest): Choose One
2. What areas of concern do you have for your student’s social skills?
Making friends
Staying out of social
Allowing others to have
Keeping friends
Drama
their views
Picking positive friends
Making good choices
Maintaining self-esteem
Having diverse groups of
(getting work done,
Recovering from setfriends
avoiding drugs/alcohol)
Backs
Reading social cues
Being a leader
Growing into new
Responding positively to
Standing up for what is
interests
social cues
right
3.
How does your student respond to instructions, structure, and authority? Check all that apply.
Easily w/ room for
Growth
Easily w/choices
Easily w/written
Expectations
Well but needs
encouragement
Well and needs gentle
Approach
Well when choices are
Given
OK but needs support
OK but needs firm
Delivery
OK but best w/out too
many choices
Needs explanation
Needs written guidance
Not well and needs to
feel has a say
Not well but relaxes w/
Support
Rejects direction
4.
How does your student respond to individual work? Choose One
5.
How does your student respond to group work? Choose One
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?
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?
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Rejects direction until
feels safe
Rejects direction unless
written expectations
Takes direction
Personally
Avoids
responsibility/ownership
Develops personality
conflicts w/ authority
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
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.
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