HORIZON SCIENCE ACADEMY
6000 South Marginal Rd., Cleveland, OHIO 44103

APPLICATION FOR ADMISSION FOR THE ACADEMIC YEAR 2003-2004

 

DEAR PARENTS AND APPLICANT:

Thank you for your interest in HORIZON SCIENCE ACADEMY. Please fill out this application form completely. Falsifications, misrepresentations, or omissions may disqualify your application. Information you supply will not be given to any other person/company for any purpose. Applications received unsigned, incomplete, or after the closing date may not be considered for acceptance.


"*" Indicated fields must be filled


Applicant's Personal Information

* Last Name: Middle Name: * First Name:
* Date of Birth: (M/D/Y):




Applicant's Address Information

* Address : * City: * Zip Code:
* Home Phone #: Guardian Phone:
Email Address(if the student has one):




School information

* Current School: School District:
School Address:
School Phone Number: School Fax Number:
* Years Attended : from to
* Grade Applying For: 6 7 8 9 10 11
* Is the applicant currently under expulsion from any school or school district? Yes No If yes, Explain:
* Does the student have any learning disabilities? Yes No If Yes, Explain:
If Yes, does the applicant currently have Individual Education Plan (IEP)? Yes No
* Has applicant ever skipped a grade? Yes No If Yes, Which Grade:
-
* Please indicate any chronicle health, emotional, or physical problem the student has,or other needs which we should be made aware of, which will help us plan and provide for applicant's educational experience.


Applicant's Family(Parent/ Custodial Parent/ Guardian)

* Relation to Applicant:    
* First Name * Last Name
* Address * City
* Zip Code
* Home Phone Work Phone
E-mail    
Employer's Name Job Position/Title:
Employer's Full Address
* Applicant lives with Mother Father Both Other, who?:


Check all that are applicable:
Parents Married
Parents Separated
Parents Divorced
Mother Deceased
Father Deceased
Other Explain: 



-How did you learn about HSA?
Brochure, flyer, handout Internet Journal
Relative Other Explain:
Briefly state why you wish to have your child/children enrolled at Horizon Science 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, omissions, or misrepresentations of facts may result in rejection of this application or future dismissal of the applicant.