Student Registration Form

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Academia Private School

Student Name (Last, First, Middle):

Date of Birth:

YYYY

Age:

Place of Birth:

LAST GRADE COMPLETED

PARENT NOTES: Please include details on your child’s academic standing, specifically in Language Arts and Mathematics. Do they perform at, above, or below level. If they perform above or below level, what grade do you believe or have been told they are at?

PARENT NOTES: Please include details about the difference in student performance in classes and what you think contributes to that.

PARENT NOTES: Please include details about student behavior in class and socially.

SPECIAL EDUCATION INFORMATION: Does the student receive special education services? Please indicate below

HOME ADDRESS (House number, Street name, Apt #, City, State, ZIP):

Home Phone Number:

Family or friends in attendance at school:

Other languages spoken at home:

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