The Creekside School Admissions Interest Form

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Thank you so much for your interest in The Creekside School! Please fill out this form in its entirety.

Email *

Student's Full Name *

Parents' Full Name(s) *

Parent E-mail *

Phone Number *

Student's Birthday *

YYYY

Age *

Current Grade Level *

School District *

District contact (if known)

Is your students IEP Team and District supportive of a change in placement for your student or in the process of looking for a new placement? *

When are you seeking placement for your student? *

Immediately

As soon as the IEP Team/District approves

Next school year

We are able to wait

Only looking/interested for now

Other:

Please select the closest description of your child's current placement. *

Self-contained special day program

Self-contained special education for students with autism

Self-contained special education for students with behavior and emotional disorders

Self-contained special education with various disabilities

Some time spent in general education; some time spent in a special education classroom

General education classroom with support from a teaching assistant

General education classroom with modifications and/or accommodations, but not additional staff support

Please select the best description of your child's current communication abilities. *

My child is a fluent communicator and is often perceived as "typical."

My child is verbal, but struggles with grammar, context, complex sentence structure.

My child is verbal, but uses simple sentences to communicate basic wants and needs.

My child is verbal, but uses 1-2 word utterances for basic wants and needs.

My child is non-verbal, but uses PECS, Sign Language, or an AAC Device to communicate independently.

My child is non-verbal, but uses PECS, Sign Language, or an AAC Device to communicate basic wants and needs.

My child is non-verbal, but will communicate through gestures and verbal approximations.

My child does not currently have a functional way to communicate his/her basic needs.

Other:

Required

Check all that apply: *

My child has a history of refusal behaviors

My child has a history of elopement behaviors

My child has a history of sensory-seeking behaviors

My child has a history of self-injurious behaviors

My child has a history of aggressive behaviors towards peers

My child has a history of aggressive behaviors towards adults

My child has a history of negative verbal behaviors towards peers

My child has a history of negative verbal behaviors towards adults

My child has a history of negative verbal behaviors towards themselves

My child has a history of silly/distracting behaviors

Required

What toileting assistance does your child need? *

Completely independent

Requires adult supervision to stay on-task

Requires prompting to be independent

Requires physical assistance

Wears diapers/pull ups

Is your child fully up to date on vaccinations? (If other please explain below.) *

Yes

Other:

If you answered other above, please explain.

Check all that apply: *

My child has no other daily living needs

My child needs support with feeding

My child needs support with eating or meal times

My child needs support with hygeine

My child needs support with managing his/her belongings

Required

Please use the space below to explain why you chose Creekside as a possible school for your child to attend and provide any additional information about why your current school placement is not meeting your child's needs.

A copy of your responses will be emailed to the address you provided.

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