|
|
HMMA has an admission policy and does not discriminate on the basis of gender, race, color, religion, ethnic, or national origin. |
|
|
*Last Name
|
|
*First Name
|
|
Middle Name
|
|
Preferred Name
|
|
*Date Of Birth
|
|
*Gender
|
MaleFemale
|
*Home Phone
|
|
*Street Address
|
|
*City
|
|
*State
|
|
*Zip Code
|
|
*Program
|
Toddler (24 months - 3 years)
Primary (3 - 6 years)
Lower Elementary (6 - 9 years)
Upper Elementary (6 - 9 years)
|
Ethnicity(Optional)
|
African American
Asian American
Caucasian
East Asian
Middle Eastern
Latino/Hispanic
Native American
Pacific Islander
Other
|
|
|
|
Last Name
|
|
First Name
|
|
Middle Name
|
|
Preferred Name
|
|
Street Address
|
|
City
|
|
State
|
|
Zip Code
|
|
Home Phone
|
|
Cell Phone
|
|
Employer / Business
|
|
Work Phone
|
|
Email
|
|
|
|
Last Name
|
|
First Name
|
|
Middle Name
|
|
Preferred Name
|
|
Street Address
|
|
City
|
|
State
|
|
Zip Code
|
|
Home Phone
|
|
Cell Phone
|
|
Employer / Business
|
|
Work Phone
|
|
Email
|
|
|
|
Last Name
|
|
First Name
|
|
Middle Name
|
|
Preferred Name
|
|
Street Address
|
|
City
|
|
State
|
|
Zip Code
|
|
Home Phone
|
|
Cell Phone
|
|
Employer / Business
|
|
Work Phone
|
|
Email
|
|
|
|
Name
|
|
Age
|
|
School
|
|
|
|
Name
|
|
Age
|
|
School
|
|
|
|
Name
|
|
Age
|
|
School
|
|
|
|
Name
|
|
Age
|
|
School
|
|
|
|
Name
|
|
Age
|
|
School
|
|
|
|
Name
|
|
Age
|
|
School
|
|
|
|
Names
|
|
Address
|
|
City
|
|
State
|
|
Zip Code
|
|
Phone
|
|
Email
|
|
May we send this grandparent(s) school information and invitations to special school events?
|
YesNo
|
|
|
Names
|
|
Address
|
|
City
|
|
State
|
|
Zip Code
|
|
Phone
|
|
Email
|
|
May we send this grandparent(s) school information and invitations to special school events?
|
YesNo
|
|
|
Child lives with (check all that apply)
|
Father
Mother
Stepfather
stepmother
Guardian
|
Check if appropriate
|
Father Deceased
Mother Deceased
Parents Divorced
Parents Seperated
|
Was child adopted?
|
YesNo
|
If adopted, what age?
|
|
Who stays with the child if both parents work regularly and when?
|
|
Which languages, other than English, are spoken at home, and to what extent?
|
|
Please list any addresses, in addition to child's custodial parent, to which school information and reports are to be mailed:
|
|
|
|
Please list schools your child has attended and for what length of time(Dates and Schools)
|
|
How did you hear about HMMA?
|
|
If you were referred by a HMMA parent, whom?
|
|
Has the applicant ever been suspended, asked to withdraw, or been expelled from a previous school?
|
Yes (If Yes, please explain in an accompanying letter)No
|
If your child has special needs, please explain here what accommodations could be provided by HMMA to allow a fair evaluation for admission:
|
|
Has the student ever participated in psychological or educational assessments or counseling? If so, please share information about it so that we can better understand your child's needs
|
|
List any medication your child takes regularly and the specific dosage for the condition:
|
|
Is there any health information we need to be aware of (allergies, physical disabilities, speech or hearing difficulties, etc..)?
|
|
|
|
What are your educational goals for this child? How do you see HMMA facilitating these goals?
|
|
How do you see this child in his/her social / emotional development?
|
|
Does this child have any hobbies, sports, or special interests, or unusual capabilities or talents?
|
|
Are you aware of any areas in which we might be able to give special help and encouragement to this child?
|
|
What role can we expect the child's parent(s) /guardian(s) to play in facilitating this child's educational goals?
|
|
Is this child's general development and academic performance in his/her present school or center consistent with your expectations for him/her?
|
|
|
|
Babbling
|
|
Simple sentences
|
|
Single word phrases
|
|
Fluency
|
|
Toilet training
|
Complete
Partial
Not at all
|
|
