HOPE SPRINGS
Christian Learning Center, Inc.

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APPLICATION FOR ENROLLMENT

An application fee of $50 must be submitted with the application prior to testing.

Name of Student _________________________________ Date ________________

Birthdate ____________ Age ______ Sex ______ Last grade attended ____________________

Last school attended __________________________________________________

Father’s name ____________________________ Occupation _________________

Mother’s name ___________________________ Occupation __________________

Home address________________________________________________________
Street City Zip County
Home phone _____________ Work phone ________________ Cell phone________

Marital status of parents: ____ Married ____ Separated ____ Divorced ____ Other (explain below)
______________________________________________________
______________________________________________________

Name of church attending ______________________________________________

Referred by _______________________ Reason ___________________________

A. FAMILY HISTORY Check where applicable.

Child is living with:
_____ natural mother (only) _____ stepmother _____ legal guardian
_____ natural father (only) _____ stepfather _____ adoptive/foster parents
_____ living with both birth parents

Other children in the home:
Name                                           Age    Grade     School
__________________________ ________ ______ _________________________
__________________________ ________ ______ _________________________
__________________________ ________ ______ _________________________
__________________________ ________ ______ _________________________
__________________________ ________ ______ _________________________
__________________________ ________ ______ _________________________

HOPE SPRINGS Christian Learning Center, Inc. admits students of any race, color, and national or ethnic origin.

Since the child’s birth, he/she has experienced: Reaction of child:

____death in the family __________________________________________
____separation of parents __________________________________________
____divorce of parents __________________________________________
____remarriage of mother __________________________________________
____remarriage of father __________________________________________
____other major trauma (identify) _______________________________________

Is there a history of learning difficulties in the immediate or extended family?
_____ yes _____no

If yes, please explain: ____________________________________________________________
____________________________________________________________
____________________________________________________________

Briefly describe your child’s relationship with you, your spouse, and the other members of the family:__________________________________________________________
________________________________________________________________
________________________________________________________________

B. MEDICAL HISTORY Check where applicable.

_____ recent physical examination Date ___________________________
_____ recent eye examination Date ___________________________
_____ recent hearing examination Date ___________________________
_____ recent speech evaluation Date ___________________________

_____ allergies (food, seasonal, environmental)
_____ asthma _____ wears glasses
_____ seizures _____ hearing difficulties
_____ speech difficulties _____ history of ear infections

Explain any item checked above:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Is the child presently on any medication?___ yes ___ no Prescribed by a doctor?___yes ___no

If yes, please identify the medication type and dosage:
_________________________________________________________________
_________________________________________________________________

Explain any noticeable effects on the child’s behavior from the medication mentioned above:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

C. DEVELOPMENTAL HISTORY Check where applicable.

Problems in infancy or early childhood:

_____ colic _____ talking
_____ crawling _____ bedwetting
_____ walking _____ sleeping
_____ eating _____ generally slow in development

Explain any item checked above:
___________________________________________________________________
___________________________________________________________________

How does the child write? _____ right-handed _____ left-handed
_____ ambidextrous _____ mirror writer

What are the child’s strengths and special interests in school and at home?
_________________________________________________________________
_________________________________________________________________

D. SCHOOL HISTORY

List all schools previously attended (pre-school to present):

School                                  Grades                  Reason for Change

_________________________ _______ ____________________________________
_________________________ _______ ____________________________________
_________________________ _______ ____________________________________
_________________________ _______ ____________________________________
_________________________ _______ ____________________________________

Check where applicable:

____ repeated grade(s) Please list:___________________________________________

____ had difficulty adjusting to change (ex: school to school, grade to grade, etc)
from__________ to ___________ from__________ to ___________

____ began kindergarten late Recommended by _______________________________

____ enrolled in special classes Recommended by _____________________________

____ participated in other supplemental services Please list:______________________
__________________________________________________________________

Please explain any items checked above: _____________________________________________
___________________________________________________________________

E. SOCIAL BEHAVIOR HISTORY Check where applicable.

Is the child:

In what areas do you feel your son/daughter needs help?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Is there any additional information you would like to share with the school about your child?
_____ yes _____ no If yes, please use the space below.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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PERMISSION FOR TESTING

We give our permission to Hope Springs Christian Learning Center to test our son/daughter for specific learning differences. The testing fee of $400.00 is due the day of testing and is not refundable.

Note: The Parental Agreement and Doctrinal Statement forms from the Prospectus packet should be signed and turned in with the Application form along with the $50.00 fee.

HOPE SPRINGS Christian Learning Center, Inc. admits students of any race, color, and national or ethnic origin.

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