Cell Phone
Work Phone
Work Phone
Cell Phone
If Other
If Other
*
*
*
*
*
*
*
*
No
Yes
If Yes, Explain :
No
Yes
Does the student have any learning disabilities?
Has applicant ever repeated a grade?
No
Yes
If Yes, Which Grade :
1
2
3
4
5
6
7
8
9
10
11
...
1
2
3
4
5
6
7
8
9
10
11
...
No
Yes
*
*
*
*
Last Name
Gender
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
January
February
March
April
May
June
July
August
September
October
November
December
Middle Name
First Name
Applicant's Personal Information
Date of Birth
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Male
Female
Grade Applying For
Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
*
Is the applicant currently under expulsion from any school or school district?
No
Yes
If Yes, Explain :
Has applicant ever skipped a grade?
If Yes, Which Grade :
If Yes, does the applicant currently have 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 applicant's 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.
*
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Years Attended From
School Fax
xxx-xxxxxxx
xxx-xxxxxxx
School District
School Phone
School Address
Current School
Applicant's School Information
to
*
*
*
*
*
*
*
*
Home Phone
Email
Zip
City
Address
Last Name
First Name
State
Secondary Parent/Guardian
Mother
Father
Legal Guardian
Other
.....
Zip
City
Address
Last Name
First Name
State
Applicant's Family Information
Applicant lives with
Both Mother and Father
Mother
Father
Other
If Other
Primary Parent/Guardian
Mother
Father
Legal Guardian
Other
Home Phone
Email
DEAR PARENTS AND APPLICANT,
Thank you for your interest in Pioneer Academy of Science. Please fill out this application form completely. After you complete and submit the online application form, One of our admission officers will contact with you.
