Student Information

Student's name: First: Middle: Last:
Student's date of birth: Student's current age:
Student's gender: ---MaleFemale Current grade level (or grade graduating): ---PreschoolKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade

To be placed on the Valley Academy waiting list for: Grade: ---Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade School Year: ---2012-2013
Kindergarten:  Half day Full Day (Full Day Kindergarten is a fee-based program.)
Please Note: If your child attended kindergarten as a 4 year old, you may be charged tuition for their kindergarten attendance.

School previously attended:

What is the primary language spoken by the student?

Special Education: has student ever been:  recommended for tested for qualified for services?
At what school? What type?

Does the child have siblings currently attending Valley Academy?  No Yes
If yes, please provide name(s) and grade(s) of siblings:

Contact Information

Home phone number: Alternate phone:
Email Address:
Street Address: City, State, Zip:

Parent Information

Mother's Name (first and last):
Mother's work number :

Father's Name (first and last):
Father's work number:

Legal Custody:  Both Parents Mother Father Other
Other - please explain:

Other Information

How did you hear about Valley Academy?

 Referred by Friend Website Great Schools Advertisement Billboard Flyer Phone Book Advertisement Other - please explain:

Would you also like to be added to the waiting list for Valley Academy's new campus, Painted Rock Academy?
Yes No