Education outside the box; Hope for every child

14225 Glen Mill Road, Rockville, MD 20850

Phone: 240-514-4475

Email: schoolteacheremail@gmail.com

Enrollment Application

Be sure to read carefully the Admissions Policy and Procedure as outlined in admissions on our website.  An application fee of $50.00 per child must accompany this application in order for it to be processed.

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_________________________________                _________________________________

Parent/Guardian                                          Spouse

_________________________________                _________________________________

Street Address                                                  City, State, Zip Code

_________________________________                _________________________________

Primary Phone                                                  Type of phone listed as primary

__________________________________________________________________

Email address(es) for parent(s) or guardian(s)

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_________________________________            

    Name of prospective student        

_________________________________

Birthday of prospective student

_________________________________              

    Child's gender

_________________________________        

Name of prospective student #2                

_________________________________              

    Birthday of prospective student #2

_________________________________

Child's gender

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Name of prospective student #3

_________________________________                

    Birthday of prospective student #3

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Child's gender

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Name and birthday of any additional prospective students

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Gender and Ethnicity of any additional prospective students

Enter the name followed by the gender and ethnicity of each student from the previous question.

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In order for us to best assist your child, please list all languages spoken at home.

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What is the primary language spoken in the home?

__________________________________________________________________________

Subject areas in which each child has struggled.

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Please explain for each child any mental or physical disabilities that require professional attention.  

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Please explain any special medical conditions (illnesses, allergies, etc.) for each child the school should know about?

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Does any child have a diagnosed learning disability or even been in a special education program or classroom?  Please give details.

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Any additional information the staff should know about each child.  If additional space is needed, please attach a separate piece of paper.

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We are interested in before or after care for our students.

Yes                No

By signing this application, I/we acknowledge that:

Parent/Guardian: ___________________________________________ Date: ______________

Spouse: _________________________________________________ Date: ______________

Note: All parents or guardians with legal custody of a child must sign this application.