Student Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian's Full Name *

First Name

Last Name

Backup Emergency Contact *

We will always attempt to contact the guardian first. If they cannot be reached, we will contact the designated backup.

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

My child currently is challenged with *

(Primary Diagnosis)

Autism Spectrum Disorder

Moderate to Severe Intellectual Disabilities

Down Syndrome

Traumatic brain injury

Deaf/blind

Visually Impaired/Blind

Multiple Disabilities

My child currently is also challenged with *

(Secondary Diagnosis)

Autism Spectrum Disorder

Moderate to Severe Intellectual Disabilities

Down Syndrome

Traumatic brain injury

Deaf/blind

Visually Impaired/Blind

Multiple Disabilities

Has this student previously applied to Perry Academy Microschool

Yes

No

Has this student previously attended Perry Academy Microschool

Yes

No

My child currently is challenged with (Medical) *

Seizure Disorder

G-Tube

Severe Allergies

Diabetes

Heart condition

Asthma

None

Does you child have any emergency medication needs, such as an inhaler, epi-pen, or prescription medication?

No, my child does not have any emergency medication.

Inhaler

Epi-Pen

Other

Does your child have an IEP or 504 plan?

Yes

No

Does your child receive the Opportunity or ESA+ grant scholarship? Check all that apply.

Opportunity Scholarship

ESA+ Scholarship

My child is able to move around most environments by themselves. *

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

My child cares for their bathroom needs by themselves. *

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree