PINNACLE ACADEMY
Online Student Application Form
   
 
  DEAR PARENTS AND APPLICANTS:
  Thank you for your interest in PINNACLE ACADEMY. Please fill out this application form completely. Falsifications, misrepresentations or omissions may disqualify your application.
   
   Applicant's Personal Information
   
      Year Applying: *
  Grade Applying: *
  Last Name: *
  First Name: *
Middle Name:
  Suffix:
  Date of Birth: *
  Gender: *
  State/City of Birth:
  Country of Birth:
  Resident Country:
Has applicant ever skipped a grade? * , If Yes Which Grade:
  Has applicant ever repeated a grade? * , If Yes Which Grade:
  Does the student have any learning disabilities? *
  if yes, Explain:
 
If Yes, does the applicant currently have an Individual Education Plan (IEP)?   *
  Please indicate any special health or educational needs of which we should be aware of and
which will help us plan and provide for the applicant's best possible educational experience:
  Please list applicant's honors, awards, or special achievements (in or out of school):
  Please list applicant's talents, interests, hobbies, club memberships, and activities:
 
 
Is the applicant currently under expulsion from any school or school district? *
  if yes, Explain:
 
   Applicant's School Information
   
  Current School: *
  School District: *
  School Address:
  School Phone:   XXX-XXXXXXX
  School Fax:   XXX-XXXXXXX
  Years Attended From:   *
 
   Applicant's Family Information
   
  Applicant lives with: * If Other  
         
  Primary Parent: * If Other: *
  Title:    
  First Name: * Last Name: *
  Street: *
  City: * State: *      Zip: *
  Home Phone: * Work Phone:
  Cell Phone: Email:
         
  Secondary Parent: If Other :
  Title:    
  First Name: Last Name:
  Street:
  City: State:      Zip: 
  Home Phone: Work Phone:
  Cell Phone: Email:
         
         
   How did you hear about PINNACLE ACADEMY ?
   
   
       
           
  Please briefly state why you wish to have your child enrolled at PINNACLE ACADEMY.  
   
 
I/We hereby certify that, to the best of my/our knowledge and belief, the answers to the foregoing questions and statements made by me/us in this application are complete and accurate. I/We understand that any false information or misrepresentations of facts may result in rejection of this application or future dismissal of the applicant.