Child's Information
First Name:
Age:
Middle Name:
Sex:
Last Name:
   
Suffix:    
Date of Birth:

Child's Home Address:		    
Street: Apt. #:
City: State:
Zip Code:    
School child is currently attending:
District:
What grade will the child be entering next year?


Primary Parent/Guardian's Information
First Name:
Middle Name:
Last Name:
Suffix:
Home Phone: - -
Cell/Pager Phone: - -
Employer:
Occupation:
Work Phone: - -
Father/Guardian's Home Address (if different from student's):
Street: Apt #:   
City:   State:   Zip:


Secondary Parent/Guardian's Information
First Name:
Middle Name:
Last Name:
Home Phone: - -
Cell/Pager Phone: - -
Email:
Employer:
Occupation:
Work Phone: - -
Mother/Guardian's Home Address (if different from student's):
Street: Apt #:  
 City: State:   Zip:

Volunteer Information
Phoenix Academy parents/guardians commit 4 hours of volunteerism per month as stated in the handbook.
If you have any parent training, hobbies, occupation, or other skills that would be valuable to our school please list: 
In what areas will you be willing to volunteer?  Please select your top three choices:
1st:   
2nd:   
3rd:


Sibling Information
First Name:    Last Name:  
 Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

First Name:    Last Name:
Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

First Name:    Last Name:   
Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

First Name:    Last Name:  
Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

First Name:    Last Name:   
Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

First Name:    Last Name:   
 Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

First Name:    Last Name:   
Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

First Name:    Last Name:
Date of Birth (MM/DD/YY):
Is this child currently enrolled in Phoenix Academy?

Emergency Contacts
Please list two additional people who may be called in an emergency and who are authorized to take child from the school:
Name:    Relationship:  
Phone:    Cell:
Name:    Relationship:   
Phone:    Cell:


Additional Information
Does the child have any allergies?  
If yes, list specific allergies:
Does the child take any medications?  
If yes, list specific medications:
Does the child have an Academically Gifted Education Plan? 
Individual Education Plan (IEP)? or a 504 plan?
Do any of the following apply to the child? 
Academically Gifted:
Behaviorally/Emotionally Handicapped:
Deaf-Blind:
Autistic:
Educable Mentally Handicapped:
Orthopedic Impaired:
Other Health Impaired:
Severely/Profoundly Mentally Handicapped:
Specific Learning Disabled:
Speech-Language Impaired:
Trainable Mentally Handicapped:
Traumatic Brain Injured:
Visually Impaired:
Please list any additional services your child requires:
Has the child ever attended any of the following? 
Speech Therapy:
Occupational Therapy:
Physical Therapy:
Educational Therapy:
Psychological Services:
If yes, please describe:
Please list any additional comments that will help us in working with your child:

Agreement and Signature

If any information is incomplete, or not completely factual, this application may be voided and must be re-submitted. Falsifying or omitting information will cancel the application process and the student will have to reapply. To the best of my knowledge, the information given for this student is accurate and complete. I acknowledge I have given all information concerning this student, and that I have read and accept all terms and conditions set forth in the Student Handbook.

Name:   Preferred Email:

Please submit your application only once.

Click to submit the application online or click to clear the application

 

 

 
Phoenix Academy • 4020 Meeting Way at Mendenhall • High Point, NC 27265 • Phone - 336.869.0079 • Fax - 336.869.3399