Roosevelt Academy

Student Application

Roosevelt Academy

Application For Admission, Grades 6 - 12

Please read before completing application:

• Roosevelt Academy accepts ESE students (EBD, EMH, SLD, & OHI) 6th - 12th.
• All applications will be screened.
• A parent/student contract must be completed to maintain enrollment.
• Roosevelt Academy only offers a Special Diploma.
• Roosevelt Academy is a School of Choice.
• Our program emphasizes a School to Work philosophy.

Student Application

1. Student Last Name:
2. Student First Name:
3. Student Middle Name:
4. Student ID #:
5. Student Social Security #:
6. Home Address:
7. Street Name, Apt. #:
8. City:
9. State:
10. ZIP:
11. Mailing Address (if different from home address):
12. Street Name, Apt. #:
13. City:
14. State:
15. ZIP:
16. Home Phone #:
17. Work Phone #:
18. Email Address:
19. Present School:
20. Present Grade: 5th6th 7th8th 9th 10th 11th 12th
21. Race - check one: White Black Other
22. Sex - check one: Male Female
23. Birth Date:
24. Has the student been suspended this year?: Yes No
25. If yes give reason:
26. Days Absent:
27. Exceptionality: EBD EMH SLD HI VI OHI
28. Has student been retained?: Yes No

29. Briefly Describe why you want to attend Roosevelt Academy

    Description:
30. I have read all the instructions and information noted above. I have also completed the application and answered all questions, and do attest to their truthfulness and accuracy. I understand I am required to sign a contract with the school prior to my child's enrollment. I understand that I will be required to sign a printed copy of this document in person at Roosevelt.
31. Parent/Guardian Name:
32. Date of Application:

 

© 2002-2009 Roosevelt Academy | Site best viewed at a resolution of 1024 x 768 or higher. Contact Webmaster