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Peace Academy
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New Student Profile

Peace Academy

Student Name*

Student Age*

Student Date of Birth*

Father's /Guardian's Name*

Phone Number

Mother's /Guardian's Name*

Phone Number

School District of Child's Residence

All Previous Schools Attended (Most Recent First)

Name of School

Last Grade Attended

School Phone Number

School Email

School Address

City

State

Zip

Name of School

Last Grade Attended

School Phone Number

School Email

School Address

City

State

Zip

Reason For Leaving Previous School(s)

Has the student repeated a grade?*

Yes

Has student been suspended, expelled or received disciplinary action?*

Yes

Does your child have any physical disabilities?*

Yes

Has your child been referred for (check one or more of the following as applicable):

Learning Disabilities

Language Processing

ADHD / ADD

Emotional Difficulties

Has your child been tested for (check one or more of the following as applicable):

Learning Disabilities

Language Processing

ADHD / ADD

Emotional Difficulties

List the subjects your child excels in

List the subjects your child has difficulty in

List any extracurricular school activities your child has participated in during the last school year, ex. clubs, Masjid activities, sports, or special programs

Provide sibling name, grade and school (If applicable)

Please specify who the student lives with?*

Both Parent

Father

Mother

Other

Child vaccinated and boosted for COVID-19?*

Vaccinated, but not boosted

Vaccinated and boosted

Please share your reasons for applying to Peace Academy

To the best of my ability, I/we have provided accurate and truthful information on this application for admission. *

Parent / Guardian Signature*

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Date*

Peace Academy

4620 S. Irvington Ave.

Tulsa, OK 74135

office@patulsa.org

918.627.1040

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