Apply to Raphael Academy: Early Childhood & Early Grades

Step 1 of 4

Applicant's basic information
School year applying for*
Grade applying for*
Please upload a photo of the child.*
Max. file size: 50 MB.
Child's name*
First Middle Last
Date of birth*
MM slash DD slash YYYY
Age*
Gender*
Residential address*
Street Address City State ZIP Code
Mailing address, if different from residential address
Street Address City State ZIP Code
Phone*
Alternate phone
Current nursery/school program*
Address*
Street Address City State ZIP Code
Grades attended*
Parent/Guardian Contact Information
Parent/Guardian 1 Name*
First Last
Relationship to child*
Address, if different from child's
Street Address City State ZIP Code
Home phone*
Mobile phone*
Work/alternate phone
Email*
Occupation
Location of work
I have another parent/guardian to add*
- Yes
- No
Parent/Guardian 2 Name*
First Last
Relationship to child*
Address, if different from child's
Street Address City State ZIP Code
Home phone*
Mobile phone*
Work/alternate phone
Email*
Occupation
Location of work
Grandparent Contact Info
Grandparent 1 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email
Phone
Grandparent 2 Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Email
Phone
Applicant Information
Height
Weight
Hair color
Eye color
Religious affiliation
Primary language spoken at home*
Emergency Contact Info
Emergency Contact 1 Name*
First Last
Relationship to child*
Address*
Street Address City State ZIP Code
Phone*
Emergency Contact 2 Name*
First Last
Relationship to child*
Address*
Street Address City State ZIP Code
Phone*

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Background Information
Thank you for answering the following questions to the best of your knowledge. This information, which will be kept strictly confidential, will help us to understand your child.
Pregnancy
Do you know of any hereditary or congenital diseases in the family on either side?*
Note any of the following conditions: genetic syndromes, autism, epilepsy, mental or nervous diseases, malformations, deafness or other serious diseases.
Describe any bleeding (during pregnancy), premature labor, infections, accidents or medical complications.*
Birth
Length of pregnancy*
Duration of labor*
Describe the birth.*
Easy or difficult, instruments used, anesthesia, C-section, etc.
Describe the neonatal course.*
For example, neonatal ICU, care, treatment for jaundice, antibiotics, spinal tap, oxygen, etc.
Did the baby require special treatment to assist breathing injections, oxygen, etc.?*
- Yes
- No
Birth weight*
Any other comments on your child’s birth.
Infancy
How was your baby fed during the first year of life? Describe any complications.*
Did the infant show affection in the usual way? Was he/she quiet or restless? Was he/she a “happy baby”?*
Were there any disturbances of digestion, recurrent vomiting, or colic? Please describe.*
Was there any unusual sleep pattern? Please describe.*
Developmental Milestones
At what age was your child exhibiting the following behaviors?
First smile*
Reaching out for things*
Teething*
Sitting unaided*
Walking unaided*
Crawling*
First word said*
What was it?*
Speaking in sentences*
Any other comments relating to infancy.
Were there periods of regression, loss of speech, etc.?*
Did your child have tics, repetitive movement patterns, fixations or self-stimulatory behavior?*
When and why did you become concerned that your child was not developing normally? What did you do about it?*
What is your child’s diagnosis? When was it first made? Has it changed over the years?*

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Drug	Dosage	Purpose	Date Started

Drug	Dosage	Why was it discontinued?	Date Started	Date Stopped

Name	Address	Reason seen	Approximate period of attendance	Advice given to you

Apply to Raphael Academy: Early Childhood & Early Grades

Apply to Raphael Academy: Early Childhood & Early Grades

Step 1 of 4

Applicant's basic information

Parent/Guardian Contact Information

Grandparent Contact Info

Applicant Information

Emergency Contact Info

Pregnancy

Birth

Infancy

Developmental Milestones

Communication

Behavior

Eating Habits

Sleeping Habits

Medical Diagnosis/Treatment

Social

Education

Parent Involvement

Final Notes

Enrollment Responsibility & Process

Parent Authorization for Release of Program/School Records and Teacher Recommendation

Application Fee

Signatures

Illness or disease	Age

Fall or accident	Age

Member's relationship to the child	Age, if sibling

Type of service	Frequency	Duration