Bridgeway Academy Application for Enrollment
Fields marked with an * are required
Student *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Gender *
Child's Birth Date *
Your answer
Parent/Guardian's First Name *
Your answer
Parent/Guardian's Last Name *
Your answer
Child's Home Street Address *
Your answer
Child's Home City *
Your answer
Child's Home State *
Child's Home Zip Code *
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Phone Number *
Your answer
Parent or Guardian Child Resides With *
Your answer
Mother's Alternate Phone Number
Your answer
Father's Alternate Phone Number
Your answer
Email Address *
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Have you taken a tour of Bridgeway Academy? *
I am interested in the following Education Center service *
I am interested in the following Therapy Center service(s)
Does your child have a current diagnosis? *
If Yes, What Is/Are Your Child's Diagnosis?
Your answer
Does your child have an IEP
If yes, is the diagnosis listed on the IEP/ETR?
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What grade level is indicated on IEP?
If no, please describe your child's needs
Your answer
Has your child attended school?
If yes, what type of classroom, what school, what district and what duration?
Your answer
What goals do you expect Bridgeway Academy to meet during the school year?
Your answer
Therapy and school services (And service provider) my child is currently receiving: (i.e. Speech, OT, PT, etc.)
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Child's Strengths (What is he/she good at?):
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Child's Deficits (What does he/she struggle with?):
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Speech/Language/Communication:
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Gross motor functioning:
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Fine motor functioning:
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Behaviors (acting out, self-injurious, preservative, etc.):
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Other comments:
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1st Payment Choice
2nd Payment Choice
3rd Payment Choice
4th Payment Choice
5th Payment Choice
Other funding source
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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. *
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