Hector E. Ponce School forAutism
1001 Cypress Creek Road, Ste 104; Cedar Park, TX 78613
Web: T: 512-710-6976
Email:
Full Name of Applicant: ______Nickname: ______Current Grade: ______Applying for School Year: ______Male ___ Female: ______
Date of Birth: ______City, State, Country of Birth: ______
Primary Language: ______
Primary Address: ______
City: ______State: ______Zip: ______
Phone: ( )______
Secondary Address (if applicable):______
City: ______State: ______Zip: ______
Phone: ( )______
Parent/Guardian Information
Parents (Check One) Married ___ Separated ____ Divorced ____ Widow/Widower: ____ Other: ______
- Relationship to Applicant (Check One)
Last Name: ______Check one Mr.____ Mrs. ____ Ms. ____ Dr. ____
First Name: ______
Occupation: ______
Employer: ______Work Phone: ______
Cell Phone/Pager: ( ) ______Email: ______
- Relationship to Applicant (Check One)
Last Name: ______Check one Mr.____ Mrs. ____ Ms. ____ Dr. ____
First Name: ______
Occupation: ______
Employer: ______Work Phone: ______
Cell Phone/Pager: ( ) ______Email: ______
Party Responsible for Payment (Check One): Father ____ Mother ____ Other: ______
Applicant’s Current School and All Prior Schools
Name of School / Dates of AttendanceFamily Information:
Siblings:
Name: ______DOB: ______
Name: ______DOB: ______
Name: ______DOB: ______
Name: ______DOB: ______
Does your family have any other relatives who currently attend or previously attended an Autism Awakening School for Autism? ______No ______Yes: ______(Location)
Why are you interested in School for Autism for your child?
What do you see as your child’s strengths and challenges?
How did you learn about Autism Awakening School for Autism? ______
Has your child consulted with a professional for educational, speech, occupational or psychological testing, counseling, guidance, ABA therapy, and/or psychotherapy in the past 3 years? _____ No ______Yes Please provide evaluation reports.
This information is used solely for the purpose of getting to know your child better, and it will not be used to deny acceptance. If yes, please attach additional sheet with the following information: names of professionals and evaluation reports. Please submit a copy with this application. Everything will be kept strictly confident according to Healthcare Portability Act (HIPPA).
Please be sure to include the following with your application (if applicable):
- Last 3 report cards
- Recent Individualized Education Plan
- Standardized Testing Results
- Private Evaluation Results
- Copy of Insurance Cards and/or DARS or CLASS information if applicable
- Copy of Drivers License
Nondiscrimination Policy
Schools for Autism admits students of any race, color, national or ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of gender, sexual orientation, race, color, and national or ethnic origin in administration of its educational policies, admissions policies scholarship and loan programs, and school administered programs or in employment of faculty and administrative staff.
Application fees are non-refundable. Tuition Assistance is available to qualified applicants.
All the information in this application is true, complete, and correct. I understand that the admissions packet is not complete until this Application, the Confidential Evaluation Forms, transcriptions and student records from previous schools. I understand that no action will be taken on this Application until packet is complete.
______
Signature of Parent or Legal GuardianDate
______
Signature of Parent or Legal GuardianDate
School For Autism
Permission for Release of Records
Please submit this form to ______with completed application.
We will fax it to your child’s school.
Applicant’s Full Name: ______
Applicant’s Birth Date: ______
Current School Name: ______
Current School Phone: ______Fax: ______
Principal/Director’s Name: ______
____ My child ______has applied for admission to ______. I hereby give permission for his/her academic records to be transferred to the school and for subsequent information to be exchanged.
_____ I give permission for representatives of ______to if needed, visit at a pre-arranged date and time, my child’s current classroom in order to observe him/her in a school setting. I understand that the information gained from the classroom visit is held in the strictest confidence and is used solely for the admission process and will not become part of the student’s permanent record file.
______
Signature of Parent or Legal GuardianDate
To Whom It May Concern:
The above named student has applied to ______. Please forward academic records to:
Organization
Attn: Admissions
Address
Or
Fax to: ______
Thank You for your cooperation!
______
Principal
Admissions Checklist for Applicants
Due Date / Item / Description / CompetedApplications for Admissions / Complete and submit application for admissions and release of records form with non-refundable evaluation fee, placements, and processing fee.
Immunization Records / Submit an up to date record of student’s complete immunizations. AAL Schools does not accept immunization waivers except in cases of medial contraindications with appropriate documentation
Tuition Assistance and Funding Application / If needed, complete and submit application for Tuition assistance, including 2015 tax return. Submit 2015 W-2 information no later than scheduled evaluation
Initial evaluation / All applicants must schedule and complete initial evaluations can be up to 3-5 days of scheduling
Student Orientation, Schedules, Evaluation Review / Students will be meeting with staff regarding schedules and evaluation results and first day of school procedures
Tuition Contract, Tuition Deposit and Enrollment Materials / Return signed tuition contracts, deposit, copy of birth certificate immunizations, student/family photos.
Tuition / Tuition is due on 1st of every month, if paying monthly.
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