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Gateway Academy Application Thank you for considering Gateway Academy for your child’s education. You may submit this application at any time; however it must be completed in full before your child can be considered for enrollment. Please note that this application process relies upon collection of information about your child from other sources. Accordingly, we recommend that you begin gathering required information before your initial meeting with Gateway Academy. Please note that we will consider mid-semester enrollments on a case-by-case basis depending upon the student’s individual circumstances and Gateway availability.

Student Name: ______________________________________________________ Date: _____________ The following must be completed before your child will be considered for enrollment: 1. Applicant Information Release Form 2. Copy of child ‘s most recent report card and unofficial copy of transcript for grades 9- 12 (if applicable and available) 3. Copies of psycho-educational evaluations, standardized test scores (ERB, TCAP, etc .), or any other relevant testing (speech/language, occupational therapy, etc.) 4. If applying to enter mid-year, information from current teacher about where the student is in the curriculum and copies of syllabi 5. A non-refundable application fee of $50.00 must be submitted with your application . Payments accepted from credit card or check made payable to Learning Lab.

Gateway Academy

at Learning Lab Brentwood

Accredited by:

5500 Maryland Way, Suite 110 Brentwood, TN 37027 Telephone (615) 377-2929 Facsimile (615) 373-8216

Gateway Academy

at Learning Lab Green Hills 3815 Cleghorn Avenue Nashville, TN 37215 Telephone (615) 321-7272 Facsimile (615) 321-1082

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Gateway Academy

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Student Information: First Name: __________________________________ Last Name: _____________________________________________ Date of Birth: ______________________________________ Age: ______________ Current Grade: _______________ Address: ________________________________________________________________________________________________ City: ________________________________________________________ State: _______ Zip: ________________________ Home Telephone: ______________________________________________________________________________________ Student’s Cell Phone (if applicable): _______________________________________________________________________ Student’s Email Address: _______________________________________________________________________________

Family Information: Mother’s Name: ________________________________________________________________________________________ Work phone: _____________________ Mobile phone: ___________________ Home phone:____________________ Email Address: _ ________________________________________________________________________________________ Home Address: ________________________________________ City: __________________ State: ____ Zip: _________ Father’s Name: _________________________________________________________________________________________ Work phone: _____________________ Mobile phone: ___________________ Home phone:____________________ Email Address: _ ________________________________________________________________________________________

If divorced, who has legal custody? (Please specify physical & educational custody rights)  Joint

 Mother ____________________________________

 Father _ ___________________________________

Address (where student resides): _ __________________________________________________________________________ City: ________________________________________________________ State: _______ Zip: ________________________ Responsible party for payment of tuition and fees: ____________________________________________________

Please list siblings with ages and schools attending: Name: ________________________________ Age: ______ School: _____________________________________________ Name: ________________________________ Age: ______ School: _____________________________________________ Name: ________________________________ Age: ______ School: _____________________________________________ Name: ________________________________ Age: ______ School: _____________________________________________

How did you hear about our program?  Past Participant

 School

 Internet/Website

 Friend

 Nashville Parent Magazine

 Other: _______________________

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School Information

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Has this child previously attended Gateway Academy?  Yes

 No

Most Recent School: ____________________________________________________________________________________ Homeschool Umbrella (if applicable): __________________________________________________________________ Describe your child’s academic strengths & challenges: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Does your child have an IEP, learning plan, accommodation plan, or other special services in place? If so, please explain. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Has your child ever skipped or repeated a grade? If so, please explain. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Has your child ever had excessive absences or been truant from school?  Yes

 No

Reason for Leaving Current School: ___________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Were there discipline problems?  Yes

 No

Were you asked to leave or expelled?  Yes

 No

If you answered yes to either of the above questions, please explain. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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School Information

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School History: Please list all schools attended. School Attended by Grade Preschool: ______________________________________________________________________________________________ Kindergarten:___________________________________________________________________________________________ 1st Grade: ______________________________________________________________________________________________ 2nd Grade: _____________________________________________________________________________________________ 3rd Grade: ______________________________________________________________________________________________ 4th Grade: ______________________________________________________________________________________________ 5th Grade: ______________________________________________________________________________________________ 6th Grade: ______________________________________________________________________________________________ 7th Grade: ______________________________________________________________________________________________ 8th Grade: ______________________________________________________________________________________________ 9th Grade: ______________________________________________________________________________________________ 10th Grade: _ ___________________________________________________________________________________________ 11th Grade: _ ___________________________________________________________________________________________ 12th Grade: _ ___________________________________________________________________________________________

Other Information: Has your child ever had a major surgery?  Yes

 No

Has your child been hospitalized for any reason?  Yes Does your child have any specialized health needs?  Yes Has your child ever had a traumatic experience?  Yes Has your child ever received counseling?  Yes

 No  No  No

 No

Has your child ever been arrested or had any involvement with the law?  Yes Does your child take any medication on a regular basis?  Yes

 No

 No

If yes, explain: __________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

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Required Background Information

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Contacts/sources 1. Educational Last School Attended: __________________________________ Last Date of Attendance: _____________________ Address: ________________________________________________________________________________________________ Contact Name:__________________________________________________________________________________________ Email: _______________________________________________________ Phone: ( _____ ) ___________________________

2. Medical Practice Name: ________________________________________ Date of Last Visit: ______________________________ Address: ________________________________________________________________________________________________ Physician’s Name:_______________________________________________________________________________________ Email: _______________________________________________________ Phone: ( _____ ) ___________________________

3. Doctor or Psychiatrist Practice Name: ________________________________________ Date of Last Visit: ______________________________ Address: ________________________________________________________________________________________________ Doctor’s Name:_________________________________________________________________________________________ Email: _______________________________________________________ Phone: ( _____ ) ___________________________

4. Counselor or Therapist Practice Name: ________________________________________ Date of Last Visit: ______________________________ Address: ________________________________________________________________________________________________ Therapist’s Name:_______________________________________________________________________________________ Email: _______________________________________________________ Phone: ( _____ ) ___________________________

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Parent /Guardian Consent to Release Medical Information

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Student Name: ____________________________________ Date of Birth (MM/DD/YYYY): _________________________ Physican Name: ________________________________________ Date of Last Visit: _____________________________ Address: ________________________________________________________________________________________________ Contact Name:__________________________________________________________________________________________ Email: _______________________________________________________ Phone: ( _____ ) ___________________________

Release of Information The student named above is applying for entry into Gateway Academy at the Learning Lab, a private school in Middle Tennessee. To help us in our admission process, we require certain information from third parties that have knowledge of the above named child’s educational, medical and/or family background. This release form, when signed by the parent or legal guardian, serves as your authorization to release this patient’s records and allow verbal communication between this party and Gateway Academy at the Learning Lab. This information will be used to make decisions relating to the student’s educational needs.

Parent/Guardian Consent I hereby authorize Gateway Academy at Learning Lab to obtain records from the above named physician or medical practice pertaining to current and previous medical conditions and/or the health status of my child, and grant permission to the provider to release this information. This written consent is valid for one year from the date below, or until a written request to cease is presented. I understand that I may withdraw this written consent at any time.

Signature: _________________________________________________ Date (MM/DD/YYYY): _________________________

Parent/Guardian

Address: __________________________________________________________ Phone: ( _____ ) _____________________ City: ________________________________________________ State: ________ Zip:________________________________

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Parent /Guardian Consent to Release Academic Information

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Student Name: ____________________________________ Date of Birth (MM/DD/YYYY): _________________________ School Name: ________________________________________ Dates Attended: ________________________________ Address: ________________________________________________________________________________________________ Contact Name:__________________________________________________________________________________________ Email: _______________________________________________________ Phone: ( _____ ) ___________________________

Release of Information The student named above is applying for entry into Gateway Academy at the Learning Lab, a private school in Middle Tennessee. To help us in our admission process, we require pertinent educational information from the above named child’s previous school. This release form , when signed by the parent or legal guardian, serves as your authorization to release this student’s records and allow verbal communication between this party and Gateway Academy at the Learning Lab. This information will be used to make decisions relating to the student’s continuing educational needs.

Parent/Guardian Consent I hereby authorize Gateway Academy at Learning Lab to obtain records from the above named school pertaining to academic record and educational information of the above named child, and grant permission to the school to release this information. This written consent is valid for one year from the date below , or until a written request to cease is presented. I understand that I may withdraw this written consent at any time.

Signature: _________________________________________________ Date (MM/DD/YYYY): _________________________

Parent/Guardian

Address: __________________________________________________________ Phone: ( _____ ) _____________________ City: ________________________________________________ State: ________ Zip:________________________________

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Parent /Guardian Consent to Release Counseling Information

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Student Name: ____________________________________ Date of Birth (MM/DD/YYYY): _________________________ Counselor/Therapist Name: ________________________________________ Date of Last Visit: _ _______________ Address: ________________________________________________________________________________________________ Contact Name:__________________________________________________________________________________________ Email: _______________________________________________________ Phone: ( _____ ) ___________________________

Release of Information The student named above is applying for entry into Gateway Academy at the Learning Lab, a private school in Middle Tennessee. To help us in our admission process, we require certain information from third parties that have knowledge of the above named child’s educational, medical and/or family background. This release form, when signed by the parent or legal guardian, serves as your authorization to release this child’s records and allow verbal communication between this party and Gateway Academy at the Learning Lab. This information will be used to make decisions relating to the student’s educational needs.

Parent/Guardian Consent I hereby authorize Gateway Academy at Learning Lab to obtain records from the above named professionals pertaining to current and previous testing , counseling and services provided to my child, and I grant permission to the provider to release this information. This written consent is valid for one year from the date below , or until a written request to cease is presented. I understand that I may withdraw this written consent at any time .

Signature: _________________________________________________ Date (MM/DD/YYYY): _________________________

Parent/Guardian

Address: __________________________________________________________ Phone: ( _____ ) _____________________ City: ________________________________________________ State: ________ Zip:________________________________

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Parent Expectations

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My major goals for my child for the upcoming school year are: 1. _______________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

I desire to have my child enrolled at Gateway Academy for the school year or semester beginning in Month ________________________________________________________ Year ____________________________________

I warrant that the information provided in this application is accurate in its entirety and that I am the financially responsible parent or legal guardian of this child. My non-refundable application fee of $50 is enclosed or has already been paid by cash or credit card. Print Name: ____________________________________________________________________________________________ Signature: ______________________________________________________ Date: _________________________________

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