Impact Academy - Where the Sky's the Limit

Student Name

Student Birthdate

Student Gender

Student Address

Student City

Student State

Student Zip

Student Country

Will a sibling be joining? If so please fill out a seperate application

School the student is currently enrolled in:

Grade level in which the student is applying for admission

Are you interested in school lunch being provided (additional fee)

Are you interested in before/after care? See schedule below

Has student ever been discharged due to behavior?

Is the student currently taking any medication? If so, please list below

Does any medication need to be dispersed to the student during the school day

Does the student have any allergies? If so, please list below

Does the student have a current IEP (Special Education Plan) If yes, please attach

Special Education Plan

Does the student have a 504 Plan (Accommodation Plan) If yes, please attach

Accommodation Plan

Who is your childs insurance carrier?

Does the student have (or previously had) a personal one-on-one or two-on-one aide during class?

If your child has an official diagnosis, please describe

Whats is your child's matrix score

Reason for interest in a new school

Mother Name

Mother Phone

Mother Work Phone

Mother Email

Mother Address

Mother City

Mother State

Mother Zip

Mother Country

Mother Occupation

Father Name

Father Phone

Father Work Phone

Father Email

Father's Address (If Different)

Father City

Father State

Father Zip

Father Country

Father Occupation

Who has custody of the child? (if divorced)

Are you willing to volunteer 15 hours per year for fundraising events?

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Registration - Seffner Campus

Student

Questionaire

Parent Info

Useful Links

Locations

News letter