Apply to Raphael Academy: Transition Apply to Raphael Academy: Transition Step 1 of 3 33% Applicant's Basic InformationSchool year applying for*2020–20212021–20222022–2023Grade applying for*5th6th7th8th9th10th11th12thPlease upload a photo of the applicant.*Child's name* First Middle Last Date of birth* Date Format: MM slash DD slash YYYY Age*Gender*Residential address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing address, if different from residential address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate phoneCurrent school/program*Name of school/programAddressGrades attendedPrevious school(s)/program(s)Click the plus sign to the right to add additional rows.Name of school/programAddressGrades attended Parent/Guardian Contact InformationParent/Guardian 1 name* First Last Relationship to child*Address, if different from child's Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home phone*Mobile phone*Work/alternate phoneEmail* OccupationLocation of workI have another parent/guardian to add*YesNoParent/Guardian 2 name* First Last Relationship to child*Address, if different from child's Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home phone*Mobile phone*Work/alternate phoneEmail* OccupationLocation of work*Grandparent Contact InfoGrandparent 1 Name First Last Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneGrandparent 2 Name First Last Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneEmergency Contact InfoEmergency Contact Name* First Last Relationship to child*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home phone*Mobile phone*Work/alternate phoneEmail* OccupationLocation of work Child's ProfileWhat type(s) of intervention/instruction did your child receive at their previous school?*Please attach a copy of the most recent school reports/records/IEP.*Has your child been seen by a psychiatrist, physiologist, or counselor?*YesNoPsychiatrist, psychologist, or counselor*Click the plus sign to the right to add additional rows.Doctor's nameProfessionAddressPhone Has your child been seen by a developmental pediatrician or neurologist?*YesNoDevelopmental pediatrician or neurologist*Click the plus sign to the right to add additional rows.Doctor's nameProfessionAddressPhone Does your child have a diagnosis?*YesNoPlease indicate the diagnosis, any secondary diagnoses, and who gave the diagnosis.*Click the plus sign to the right to add additional rows.DiagnosisWho gave the diagnosis? Please indicate whether your child exhibits any of the following behaviors.* Self injurious behavior (head banging, cutting, biting, etc.) Aggression towards others (biting, kicking, spitting, hitting, etc.) Difficulty transitioning from place to place or from task to task Obsessive Compulsive issues (the need for things to be done a certain way) Fleeing/running away A sleeping disorder Sensory issues (sensitive to touch, sound, light, motion, etc.) Please describe any self injurious behavior.*Please describe any aggression towards others.*Please describe any difficulty transitioning from place to place or from task to task.*Please describe any Obsessive Compulsive issues.*Please describe any fleeing/running away behavior.*Please describe any sleeping disorder(s).*Please describe any sensory issues.*Does your child respond to their name when called?*YesNoMedical NeedsDoes your child have a medical diagnosis?*YesNoPlease describe.*If yes, please attach copies of any psychological evaluations, educational evaluations, Occupational or Speech Therapist evaluations.* Drop files here or Please indicate your child’s health / medical needs other than the predominate medical diagnosis.Does your child have allergies?*YesNoPlease describe your child's allergies.*Does your child take any routine maintenance medication or supplements?*YesNoPlease indicate type and dosage.*Click the plus sign to the right to add additional rows.Type of medicationDosage Does your child require a special diet of any kind?*YesNoPlease describe your child's special diet.*Does your child have any physical disabilities?*YesNoPlease describe your child's physical disabilities.*Is your child potty trained?*YesNoAt what age was your child potty trained?*Please describe your child's toileting needs.*Describe any medical, physical, psychological, behavioral and/or other needs, conditions or concerns about the child that would assist the school & staff to best support the child.Language & CommunicationMother's language*Others spokenFather's language*Others spokenWhat language is spoken in the home?*Is your child verbal? Does he/she request his/her needs and wants to answer social questions etc.?*YesNoPlease describe your child’s verbal skills.*Please describe your child’s receptive listening skills. Will he/she follow directions verbally?*Does your child receive Speech Therapy?*YesNoHow often per week?*Name of speech therapist*Does your child receive OT or PT?*YesNoHow often per week?*Name of OT or PT therapist*Please list any other therapies or classes your child attends regularly (music, dance, movement, etc.).Social & Play SkillsMy child...* Prefers to be alone. Prefers to be on the fringe of groups of peers. Enjoys social interaction with individual peers. Enjoys social interaction with individual adults. Enjoys social interaction with groups of peers. Plays appropriately alone. Plays appropriately with peers. Demonstrates repetitive play. Engages in stereotypic activity when undirected. Additional comments on social & play skills:RelationshipsMy child...* Ignores the presence of others. Makes eye contact with others. Anticipates with excitement. Enjoys simple adult-led games. Participates in partner games. Understands games with rules. Tolerates changes to activities. Improvises when playing. Additional comments on relationships:Likes & DislikesPlease describe your child’s preferred activities, interests and reinforcements.*Please describe activities that your child dislikes.*List any particular object(s) or situation(s) which your child finds distressing (e.g. crowds, unfamiliar situations, noises).*Child's Family ProfileChild resides with:*Parents’ relationship status*MarriedSingleDivorcedSiblingsClick the plus sign to the right to add additional rows.NameAgeSchool/program currently attending Child’s daily routine*Describe a typical day for your child.Child’s daily sleeping schedule*Sleeps through night, only a few hours, needs medication to sleep, etc.Child’s interests/hobbies*Time spent watching television/movies/videos*DailyWeeklyTime spent on computer/playing electronic games*DailyWeekly Enrollment Responsibility & ProcessRaphael Academy is a sponsored project of Waldorf Education Association of New Orleans. Waldorf Education Association of New Orleans is a not for profit 501(c)(3). Complete financial responsibility for student’s initial and continued enrollment, until otherwise changed in writing, will be assumed by:Name* First Last Relationship to child*Name First Last Relationship to childPlease complete and submit the Authorization for Release of Student Records to the student’s previous school/program. Current school records will need to be obtained by Raphael Academy to a final decision for student’s acceptance.Upload your completed Authorization for Release of Student Records.*Application FeePlease enter the name, confirmation email, and billing address that should be associated with your application fee payment below. Once you submit this application, you'll be redirected to our PayPal online payment portal, where you may complete your non-refundable $50.00 application fee payment.Application Fee* Price: $50.00 Name* First Last Confirmation Email* Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SignaturesOnce the above items are received, you will be contacted by phone to schedule an Entrance Interview for you and your child. Applicants are considered for admission without regard to race, color, creed, or national or ethnic origin.Name of parent/guardian 1* First Last How would you like to provide your signature?*I would like to digitally sign my name.I would like to type my signature.Parent/guardian 1 signature*Use the box below to sign your name. Click the refresh icon at the bottom right to clear the box.Parent/guardian 1 signature*Type your full name. This will serve as your digital signature.Name of parent/guardian 2 First Last How would you like to provide your signature?I would like to digitally sign my name.I would like to type my signature.Parent/guardian 2 signatureUse the box below to sign your name. Click the refresh icon at the bottom right to clear the box.Parent/guardian 2 signatureType your full name. This will serve as your digital signature.CAPTCHANameThis field is for validation purposes and should be left unchanged.
