A school for students with academic, social and emotional challenges.

Southern Raised Learning
Enrollment Application

Please fill out this enrollment application. It will be sent to us directly and we'll contact you to schedule an introductory meeting.

The information on this form is confidential and will not be shared with anyone.

Student Informaton

Student Name

Nickname

Date of Birth
Address:

School Information

Current School:

Grade:

Address:

Contact Person:

Please list previous schools that your child has attended.

School Name:

Grade:

Address:

Contact Person:

Have you ever been asked to pick up your child from school due to a behavior issue? Has your child’s school, past or present, ever filed an incident report related to inappropriate behavior displayed at school? Has your child ever been suspended from school?

Siblings

Name:

Date of Birth:

School:

Name:

Date of Birth:

School:

Name:

Date of Birth:

School:

Medical Information Pediatrician Name: Address: Phone: Email:

Psychiatrist/Psychologist: Address: Phone: Email:

Counselor/Therapist Name: Address: Phone: Email:

Neurologist Name: Address: Phone: Email:

Other Medical/Wellness Professional: Address: Phone: Email:

What other services is your child currently receiving during the school day? (speech therapy, occupational therapy, physical therapy, etc.) Does your child take medication? If so, please list the name and dosage of each one. How did you hear about Southern Raised Learning?
(If it was a referral, please list the name, phone number and relationship of the person who referred you.) What attracted you to Southern Raised Learning? (If you visited the website, what ‘peaked’ your interest?) Are there areas of your child’s education or well being that you are particularly concerned with? In your opinion, what do you see as strengths in your son/daughter? Please list weaknesses, as well. What signs/things will you be looking for that will tell you that you’ve made the right decision in sending your precious learner to Southern Raised Learning?

After submitting this application, we will contact you to set up an initial meeting with the director.
Please bring the following items to your initial meeting:

Most recent psychological report
Most recent speech/language, occupational therapy or physical therapy report
Most recent report card
Most recent IEP, 504 Plan, or any other plans relevant to his/her school day

Your Name: I prefer you contact me by:
Phone Email

The information submitted on this form is confidential and will not be shared with anyone.

Southern Raised Learning Enrollment Application

Southern Raised Learning
Enrollment Application