The Academy

For Mathematics and Natural Sciences

A $50 processing fee, a current photo of your student, transcripts

from your students last school and copies of all pertinent testings
as determined by the admissions director after your initial
consultation must accompany this application.

Date ________________

Thank you for your interest in The Academy For Mathematics And Natural
Sciences. The information you supply on this application will help to determine if
your student is an appropriate match for The Academy. Following receipt of all
available information, a student screening will be scheduled. Please do not hesitate
to call us at any time for assistance or with any questions you might have.

Student:
Name ___________________________________________________
Social Security Number ______-____-______
Birthdate _______/_______/_______
Please indicate: _____ Male _____ Female
Address ________________________________________________
City ______________ State ________ Zip Code _______

Parent/Guardian:
1.
Name ____________________________________________________
Email:__________________________________
Home Phone ( _____) _____ - ________
Cell Phone ( _____) _____ - ________
Work Email: _____________________________
Address ________________________________________________
City ______________ State ________ Zip Code _______
Occupation _________________________
Employer ______________________
Bus. Phone ( ______ ) ______ - __________

2.
Name ____________________________________________________
Email:__________________________________
Home Phone ( _____) _____ - ________
Cell Phone ( _____) _____ - ________
Work Email: _____________________________
Address ________________________________________________
City ______________ State ________ Zip Code _______
Occupation _________________________
Employer ______________________
Bus. Phone ( ______ ) ______ - __________

Please indicate the person or agency that referred you to The Academy:

__________________________________________________________________
__________________________________________________________________

Educational History:
Present School ___________________________________________________
Present Grade ______ School District (if applicable)______________________
Address (of school) ________________________________________________
City ________________ State ________

Zip Code __________

Telephone (______) ______ - __________

Teacher or councilor most familiar with your student: _____________________
List all schools attended by grade and year. Please be specific about grades
repeated. Continue on back if necessary.
_______________________________________________________________________

Grade

School

Year

_______________________________________________________________________

Grade

School

Year

_______________________________________________________________________

Grade

School

Year

_______________________________________________________________________

Grade

School

Year

_______________________________________________________________________

Grade

School

Year
3

Please indicate if there are any specific academic deficits you believe are
inherent in your student:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

What do you feel are your student's greatest academic strengths:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
What do you feel are your students greatest academic weaknesses:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Please provide any academic notes or provide any further information you
feel appropriate to share with the admissions director in the space below:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Health History
Please indicate if there are any health concerns you wish to share with us:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Date of childs last physical examination:
___________________________________________
At any time, has your child had the following (Please elaborate as appropriate):
1. Asthma _________________________________________________________
2. Allergies _______________________________________________________
3. Diabetes, arthritis or other chronic illness ______________________________
4. Epilepsy ________________________________________________________
5. Seizures ________________________________________________________
6. Chicken pox or other common childhood illnesses
____________________________________________________________
7. Heart or blood pressure problems ____________________________________
8. High fevers (over 103 degrees) ______________________________________
9. Surgical procedures _______________________________________________
10. Speech or language problems _______________________________________
11. Chronic ear infections ____________________________________________
12. Hearing difficulties _______________________________________________
13. Eye or vision problems ____________________________________________

14. Fine motor/ handwriting problems ___________________________________

15. Gross motor problems ____________________________________________
16. Appetite problems _______________________________________________
17. Sleep problems (falling asleep/staying asleep) _________________________
18. Treatment related to drug use ______________________________________
19. Treatment for depression __________________________________________

Are there any medications your student is currently taking: ( Yes / No )

If Yes:
Name of medications:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Supervising Physician: _______________________________________________
Contact number for supervising physician: _______________________________
Purpose of medication:
__________________________________________________________________
__________________________________________________________________
My child has in-depth medical attention for the following conditions: (please do
not include routine illnesses)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________