Preliminary Application

 

Please print clearly.  If additional space is needed, please use a separate sheet of paper. Please understand that it is our desire to help all students.  If we feel that we are unable to assist your child we can provide you with referrals to other facilities.

 

Student’s Name: ________________________________________  Age: _____   DOB:____________

Parent’s Name: _________________________________________  Phone:______________________

Address:_______________________________________________ Wk Phone:___________________

City, State, Zip: _________________________________________ Wk Phone:___________________

Email:                                                                                                   

 

Where is the student currently residing? __________________________________________________

 

How did you hear about New Creations? _________________________________________________

 

Briefly explain why you are seeking placement for your child:_________________________________

___________________________________________________________________________________

 

Briefly describe your child’s disruptive or acting out behavior:________________________________

___________________________________________________________________________________

 

When did these behaviors begin? _______________________________________________________

__________________________________________________________________________________

 

Please list any contributing factors to this negative behavior:_________________________________

___________________________________________________________________________________

 

Please list any behavioral medications your child  has or is taking:_____________________________

___________________________________________________________________________________

 

Please give a brief description of students religious background and experience.__________________

___________________________________________________________________________________

 

To your knowledge, has the student been sexually or physically abused?  Please explain:___________

___________________________________________________________________________________

 

Has this been reported or investigated? __________________________________________________

 

 

 

 

 

 

______________________________        __________        _____________________________

Parent Signature                         Date                                           Parent Signature

 

  New Creations Christian School, Boarding School, and Bible College admits students of any race, color, and national or ethnic origin. This school is authorized uner Federal law to enroll nonimmigrant students.