CasaBlanca Academy Application for Student Admission

2014- 2015

_________________________________________________
Applicants Name
_________________________________________________
Applicants Address
_________________________________________________
Applicants Phone Number
_________________________________________________
Name of person filling out application and phone number

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org

Dear Parents,
We are delighted that you have chosen to apply for your child to attend CasaBlanca Academy for
the 2014-2015 school year. To assist you in the application process please read and follow the
application process below:
1. Applicants should complete the application provided and submit along with a nonrefundable $250 application fee.
2. School records, reports and evaluations completed within the prior year by professionals
who work with the student should also be submitted with the application.
3. To accompany the written application, please submit a video of the child using the
specifications provided. The videos should be 10 to 15 minutes in length and should
include two segments: 1) the child participating in an activity in which he or she interacts
with a parent or peer and 2) the child participating in an enjoyable activity. You may send
in the DVD or email videos to lizzie@casablancaacademy.org.
4. After the application has been submitted in full, CasaBlanca Academy will notify parents.
5. If the child is being considered for admission, the applicants parents or guardians will be
scheduled for interviews, along with the applicant. The applicant will be scheduled for a
one to two hour informal observation with the parents, classroom lead teacher and
Director of Education.
6. Following completion of the application, video review, observation with the child and
interview with the parents, parents will be notified of their childs acceptance status.
7. If the child is not enrolled at CasaBlanca Academy, all application materials will be
returned to the parents or destroyed to protect confidentiality
CasaBlanca Academy professionals and outside consultants will help determine if your child is an
appropriate fit for CasaBlanca Academy and whether CasaBlanca Academy can meet your childs
needs. Except for extenuating circumstances, parents are asked to commit for the academic year.
CasaBlanca Academy will notify parents of acceptance into the program. Parents will then be
required to send in the tuition deposit of $2500 (non-refundable) to secure their childs placement
into the program.
If you have any questions during the application process feel free to call or email me and I will be
happy to assist you through the process.
Sincerely,
Lizzie Bicknell
VP of Administration and Development

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org

Application
Todays Date: __________________________
Applicants Name ________________________________________________________
Last
First
Middle
__________________________________
Nickname
Date of Birth: _____________________________
Gender: _____Male

_____Female

General Information
Are Both Parents Living? ____________Divorced? ________Separated? ___________
If divorced or separated, with who does the child primarily live with? ______________
Mothers Information:
Name: ______________________________
Address: ______________________________________________________
Street
_____________________________________________________________________
City
State
Zip
Home Telephone: ________________________ Cell: __________________________
Occupation: _____________________________Work number: __________________
Email: ________________________________
Fathers Information:
Name: _____________________________
Home Address (if different from above):
________________________________________
Street
________________________________________________________________
City
State
Zip
Occupation: _______________________________
400 N 35th Avenue w Hollywood, Florida w 33021
Phone: 954-415-1149 w www.casablancaacademy.org

Place of Employment:
_________________________________________________________________
Name
Address
Home phone: __________________ Cell Phone: ____________________
Work Phone: __________________ Email: _________________________
Guardians information (if applicable):
Name(s): ______________________________
Address: ______________________________________________________
Street
_____________________________________________________________________
City
State
Zip
Home Telephone: ________________________ Cell: __________________________
Occupation: _____________________________Work number: __________________
Email: ________________________________

School Information
Where does your child attend school now? _______________________________
Grade level? __________
Reason for leaving:
_______________________________________________________________________
How did you hear about CasaBlanca Academy?
_______________________________________________________________________
Names and ages of other children in family and name of the schools currently attending:
Name

Age

School Attending

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org

Medical and Therapeutic Information

Childs Pediatrician:
___________________________________________________________________
Name
Phone
_______________________________________________________________________
Address
Has your child been seen by a Psychiatrist, Psychologist or Counselor?
YES____ NO_____ (If yes, please include all reports with application)
Childs Psychiatrist
_____________________________________________________________________
Name
Phone
_______________________________________________________________________
Address
Childs
Psychologist_____________________________________________________________
Name
Phone
_______________________________________________________________________
Address
Childs Counselor
_____________________________________________________________________
Name
Phone
_______________________________________________________________________
Address
Has your child been seen by a developmental pediatrician or neurologist?
YES____ NO_____ (If yes, please include all reports with application)
Name of professional: _________________________________________________
Date of last visit: _____________________
Does your child have a diagnosis? If yes, please indicate what the diagnosis is and who
gave the diagnosis ________________________________________________________
________________________________________________________________________
Is your child on medication? _________If yes please indicate the medicine and dosage
________________________________________________________________________
________________________________________________________________________
400 N 35th Avenue w Hollywood, Florida w 33021
Phone: 954-415-1149 w www.casablancaacademy.org

Is your child on a special diet? _____________ If yes, please describe the diet:
________________________________________________________________________
Occupational Therapist (Please submit any reports/ goals/ progress with application)
Name: ______________________________ Phone number: ______________________
Address: _______________________________________________________________
Dates of Service: _____________________ Frequency: _________________________
Speech and Language Pathologist (Please submit any reports/ goals/ progress with
application)
Name: ______________________________ Phone number: ______________________
Address: _______________________________________________________________
Dates of Service: _____________________ Frequency: _________________________
Physical Therapist (Please submit any reports/ goals/ progress with application)
Name: ______________________________ Phone number: ______________________
Address: _______________________________________________________________
Dates of Service: _____________________ Frequency: _________________________
Other (Please submit any reports/ goals/ progress with application)
Name: ______________________________ Phone number: ______________________
Address: _______________________________________________________________
Dates of Service: _____________________ Frequency: _________________________

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org

Parent Questionnaire
What are you looking for in a school program for your child? __________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please describe how your child interacts with you_____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please describe how your child interacts with peers. __________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please describe how your child interacts with siblings__________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What are your childs favorite activities?

___________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
How does your child plan for future events?
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What topics of interest does your child most like to talk about? __________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org

Please describe your childs typical play skills (include information about preferred choice of playmate,
whether your child is a follower or loner, how many peers your child is comfortable playing with, whether
your child prefers to play with toys or engage in other activities)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Describe what happens when your child is upset. What do you typically see? (kicking, biting, hurts
self/others, withdrawn, etc.) Include how your child is comforted and regulated, and how long does it
take for your child to recover.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Does your child exhibit impulsive behavior?
If yes, please describe: ___________________________________________________________________
_____________________________________________________________________________________
Does your child exhibit aggressive behavior?
If yes, please describe: ___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Does your child have any strong fears or anxiety?
If yes, please describe: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Feel free to elaborate on any aspect of your child, including descriptions of his/her motor, attention,
memory, language, mood, and/or sensory profile:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org

Describe how your child makes transitions between people, activities and environments.

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
If applicable, describe your childs comprehension of reading or math materials versus rote skills.

_______________________________________________________________________
_______________________________________________________________________
Describe a typical day for your child (include information regarding all activities)
____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org

Parents Statement
We, the parents of ________________________, attest that all information provided is
current and accurate. Note that non-disclosure or falsification of student information can
result in revoking admission.
_____________________________ Mothers signature
_____________________________ Date

_____________________________ Fathers signature

_____________________________ Date
_____________________________ Guardians signature (if applicable)
_____________________________ Date

NOTICE OF NONDISCRIMINATORY POLICY:

CasaBlanca Academy, Inc., admits students of any race, creed, or national and ethnic origin to all the rights
and privileges, programs and activities generally accorded and made available to students at the school. It
does not discriminate on the basis of race, creed, color or national and ethnic origin in administration of its
educational policies, admissions policies, or other school-administered programs.

400 N 35th Avenue w Hollywood, Florida w 33021

Phone: 954-415-1149 w www.casablancaacademy.org