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New Student Profile Form

Peace Academy

New Student Profile Form

PEACE ACADEMY

Fully Accredited Private School

Student's Name

Father's / Guardian's Name

Mother's / Guardian's Name

Student's Age

Date of Birth * required

Father / Guardian Phone

Mother / Guardian Phone

School District of Child's Residence

Schools Attended

All Previous Schools Attended (Most Recent First)

School Name (School 1)

Last Grade (School 1)

School Address (School 1)

Reason for Leaving (School 1)

Phone (School 1)

Email (School 1)

School Name (School 2)

Last Grade (School 2)

School Address (School 2)

Reason for Leaving (School 2)

Phone (School 2)

Email (School 2)

Other Info.

Has the student repeated a grade? *

Yes

No

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

Yes

No

Does your child have any physical disabilities? *

Yes

No

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

Language Disabilities

Language Processing

ADHD / ADD

Emotional Difficulties

Initial Test Date

Most Recent Test Date

If so, which grade and why? (Repeated Grade)

If so, which grade and why? (Suspended/Expelled/Disciplined)

If so, please explain. (Physical Disabilities)

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

Language Disabilities

Language Processing

ADHD / ADD

Emotional Difficulties

If you have checked any of the boxes in the "Referred" or "Tested" section above, please explain.

Please provide a copy of most recent test result.

List subjects you child excels in

List subjects your child has difficulty in.

List any extracurricular activities your child has particpated in during last school year.

1) Sibling Name

2) Sibling Name

3) Sibling Name

1) Sibling Grade

2) Sibling Grade

3) Sibling Grade

1) Sibling School Name

2) Sibling School Name

3) Sibling School Name

Please specify who the student lives with? *

Both Parents

Father

Mother

Other

Cild vaccinated and boosted for COVID-19? *

Vaccinated and boosted

Vaccinated but not boosted

No

Please share your reasons for applying to Peace Academy.

I certify that the information I provided on this form is true and accurate to the best of my knowledge.

Parent / Guardian Signature

Your Form has been successfully submitted. Please proceed to STEP 3 and fill out the Drug / Alcohol Consent Form now.

Peace Academy

4620 S. Irvington Ave.

Tulsa, OK 74135

office@patulsa.org

918.627.1040

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