Bridgeway Academy Application for Enrollment

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Fields marked with an * are required

Student *

Child's First Name *

Child's Last Name *

Gender *

Child's Birth Date *

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Child's Home Street Address *

Child's Home City *

Child's Home State *

Child's Home Zip Code *

Phone Number *

Parent or Guardian Child Resides With *

Mother's Alternate Phone Number

Father's Alternate Phone Number

Email Address *

Have you taken a tour of Bridgeway Academy? *

Yes

I am interested in the following Education Center service *

I am interested in the following Therapy Center service(s)

Speech Therapy

Music Therapy

Occupational Therapy

Psychological Services

Evaluation

Speech and Music Therapy Social Group

Physical Therapy

Summer Camp

6th-8th grade

9th grade and above

Does your child have a current diagnosis? *

Yes

If Yes, What Is/Are Your Child's Diagnosis?

Does your child have an IEP

Yes

Clear selection

If yes, is the diagnosis listed on the IEP/ETR?

What grade level is indicated on IEP?

If no, please describe your child's needs

Has your child attended school?

Yes

Clear selection

If yes, what type of classroom, what school, what district and what duration?

What goals do you expect Bridgeway Academy to meet during the school year?

Therapy and school services (And service provider) my child is currently receiving: (i.e. Speech, OT, PT, etc.)

Child's Strengths (What is he/she good at?):

Child's Deficits (What does he/she struggle with?):

Speech/Language/Communication:

Gross motor functioning:

Fine motor functioning:

Behaviors (acting out, self-injurious, preservative, etc.):

Other comments:

1st Payment Choice

2nd Payment Choice

3rd Payment Choice

4th Payment Choice

5th Payment Choice

Other funding source

Confirm Application

I affirm that the information I have stated within this application is true. I give the staff and specialists of Bridgeway Academy permission to discuss my child, using info from this application as well as any info from current therapists and teachers. *

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms