Enrollment Inquiry Form

Student Information

Student First Name

Student Last Name

Date of Birth

Student Age

Student Gender

Current School

Grade in Fall of 2024

Address

City

State

ZIP

Special Services Received (required) None Gifted & Talented Occupational Therapy Physical Therapy Speech Therapy Resource Room Other

If other - Please describe

Does this child have an IEP? (required) Yes No

Has this child ever received disciplinary action resulting in missing school? (required) Yes No

If yes - Please describe

Parent or Guardian information

Guardian First Name What is the first name of the guardian?

Guardian Last Name What is the last name of the guardian?

Cell Phone

Address, if different than student

City

State

Zip Code

Email Address

Relationship to child:

Please enter names of other children interested in attending North Central Academy

First Name (Child 2)

Last Name (Child 2)

Date of Birth

Age

Gender

Current School

Grade in Fall of 2024

Special Services Received None Gifted & Talented Occupational Therapy Physical Therapy Speech Therapy Resource Room Other

If other - Please describe

Does this child have an IEP? Yes No

Has this child ever received disciplinary action resulting in missing school Yes No

If yes - Please describe

First Name (Child 3)

Last Name (Child 3)

Date of Birth

Age

Gender

Current School

Grade in Fall of 2024

Special Services Received None Gifted & Talented Occupational Therapy Physical Therapy Speech Therapy Resource Room Other

If other - Please describe

Does this child have an IEP? Yes No

Has this child ever received disciplinary action resulting in missing school? Yes No

If yes - please describe

How did you hear about us? (required) Current NCA Family Facebook Twitter Instagram Other

Is this child a sibling to a current NCA student?

If yes, what is the NCA student's name?