Pacific Point Academy & Learning Center Application

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1 Pacific Point Academy & Learning Center Application IDENTIFYING INFORMATION Student and Parental Information Child s Date of Birth: Home Address Line1: Home Address Line 2: Today s date: Age: Gender: Application Completed By: Referred to Pacific Point By: Relationship to Child: Relationship to Child: Parent or Guardian: Address (if different ): Employer: Home Work Cell Parent or Guardian: Address (if different ): Employer: Home Work Cell Please describe in your own words the nature of your child s difficulties: How do you expect Pacific Point to help your child? Page 1 of 7

2 SCHOOL HISTORY Current School Placement Current School: Date Started: Teacher(s): Grade: Type of School: Public Private Regular Education Special Education Type of Program: Regular classroom Regular classroom with resource room, specify time in resource room: Special day class with mainstreaming, specify time in mainstream: Special day class without mainstreaming Other Schools and Special Services Directions: Please list all schools, including preschools, your child has attended other than his/her current school. Indicate if it was a public or private school and whether your child was in a regular or special education classroom. Name Type of School/Program Dates (From/To) Reason for Change Directions: Please list any special services your child is currently receiving or has received in the past. Indicate whether the service was provided at school or privately, dates of service, and reason for discontinuation. Service Current Past School Private Dates (From/To) Reason for Change Page 2 of 7

3 SCHOOL HISTORY CONTINUED Evaluations and Problem Areas Directions: Please list any evaluations your child has received through his/her school. School Areas Evaluated Date Has your child ever repeated a grade? Yes No If yes, which grade(s)? Indicate any problems in the following areas: Reading Comprehension Reversals of letters or words Writing Avoidance of school work Loses place/skips lines Math Works too hard on school work Poor memory Spelling Motivation/behavior Attention/concentration Slow work Low self-esteem Overly active Other: CONSULTANT INFORMATION Physician/Pediatrician Last Physical Exam: Page 3 of 7

4 CONSULTANT INFORMATION CONTINUED Other Consultants Directions: Please list medical and other specialists who have evaluated or are currently treating your child (for example: Neurologist, Developmental Pediatrician, Psychologist, Speech and Language Therapist). Please do not include any special service your child may be receiving currently through his/her school. Page 4 of 7

5 MEDICAL HISTORY Health Record Please describe your child s current health: Has your child received a diagnosis? Yes No If yes, please indicate below: ADD ADHD Autistic/Asperger s/pdd Dyslexia/Reading Problem Learning Disability Physical Disability Speech/Language Disability Other: Please check all illnesses that your child has or has had: Allergies Cystic fibrosis Leukemia Polio Asthma Diabetes Measles Rheumatic fever Bronchitis Ear infections Meningitis Rubella Chicken pox Encephalitis Mumps Scarlet fever Cholera Epilepsy Muscular dystrophy Seizures/convulsions Croup High fever Pneumonia Tonsillitis Other: Vision: Normal Vision Problem If vision problem, please describe: Wears glasses/contact lens Won t wear glasses/contact lens Date of last vision exam: Examined by: Hearing: Normal Hearing Problem If hearing problem, please describe: Uses hearing aid Date of last hearing exam: Examined by: Page 5 of 7

6 MEDICAL HISTORY CONTINUED Medications Directions: Please list significant medications (e.g. stimulants, anti-depressants, tranquilizers, painkillers) your child has taken beyond those prescribed for common illness. Past Medication(s): Current Medication(s): ADDITIONAL INFORMATION Is there any additional information you feel would be beneficial for us to know? Page 6 of 7

7 Pacific Point Academy Authorization to Exchange Confidential and Privileged Information I hereby give my consent for all relevant information regarding: Student DOB: to be exchanged between Pacific Point Academy and: Name or Agency: Phone Number: This is for the confidential use of school personnel. Signature: Relationship to Child: Date: Page 7 of 7

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