Lafayette School Application
Email address *
Application Date *
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Full Name of Applicant *
Your answer
Date of Birth *
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SS# *
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Parent/Guardian Information
Parent/Guardian #1 Information *
Your answer
Street Address *
Your answer
City, State, Zip *
Your answer
Does this person have custody of the applicant? *
Required
Parent/Guardian #2 Information
Your answer
Street Address
Your answer
City, State, Zip
Your answer
Does this person have custody of the applicant?
Education Information
Last School Attended *
Your answer
Current Grade Level *
Your answer
Anticipated Diploma
Anticipated Diploma Date *
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Does applicant have an IEP? *
Your answer
Estimated IQ *
Your answer
Medical Information
Please describe applicants general health. *
Your answer
Date of last physical. *
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Current Medications *
Your answer
Does the applicant have any medical problems or handicaps which might interfere with full participation in our program? *
If yes, please describe below.
Your answer
Legal History
Has applicant been involved with the Juvenile Justice System/Court Services Unit? *
If yes, please decribe below.
Required
Your answer
Is the applicant currently on probation? *
Required
Substance Abuse Information
Has the applicant ever used substances? *
If yes, please list below.
Required
Your answer
Date the applicant began using substances.
MM
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DD
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YYYY
Date applicant quit using substances. *
List today's date if the applicant is currently using substances.
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Presenting Problems
What recent events or behaviors have brought about an application for alternative academic placement? *
Suspensions, Expulsions, MDR, Threat Assessment
Your answer
What are your goals for the Applicant if they were to attend Lafayette School?
Your answer
Treatment History
Facility Name *
Your answer
Date treatment began.
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Facility Case Manager
Please list full name and contact number.
Your answer
Type of Treatment
Referral Information
Referral name *
Your answer
School System
Your answer
Address & Phone Number
Your answer
How did you learn about Lafayette School? *
Your answer
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