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New Student Profile Form

Peace Academy

New Student Profile Form

PEACE ACADEMY

Fully Accredited Private School

Student's Name

Father's / Guardian's Name

Student's Age

Student's Date of Birth

Father's / Guardian's Phone

Mother's / Guardian's Name

Mother's / Guardian's Phone

School Disctrict of Child's Residence

Schools Attended

All Previous Schools Attended (Most Recent First)

School Name

Last Grade Attended

School Address

Reason for Leaving

School Phone

School Email

School Name

Last Grade Attended

School Address

Reason for Leaving

School Phone

School Email

Other Info.

Has the student repeated a grade? *

Yes

No

Has student been suspended, expelled or received disciplinary action? *

Yes

No

Does your child have any physical disabilities? *

Yes

No

Has your child been referred for (check one or more of the following as applicable):

Learning Disabilities

Language Processing

ADHD / ADD

Emotional Difficulties

Please provide a copy of most recent test result.

Initial Test Date

Most Recent Test Date

If so, which grade and why?

If so, which grade and why?

If so, which grade and why?

Has your child been tested for (check one or more of the following as applicable):

Learning Disabilities

Language Processing

ADHD / ADD

Emotional Difficulties

If you have checked any of the boxes in the "Referred" or "Tested" section above, please explain

List subjects your child excels in.

List subjects your child ha in. difficulty in.

List any extracurricular school activities your child has participated in during the last school year, ex. clubs, Masjid activities, sports, or special programs.

1) Sibling Name

2) Sibling Name

3) Sibling Name

Grade

Grade

Grade

School Name (if applicable)

School Name (if applicable)

School Name (if applicable)

Please specify who the student lives with? *

Both Parents

Father

Mother

Other

Child vaccinated and boosted for COVID-19? *

Vaccinated and boosted

Vaccinated but not boosted

No

Please share your reasons for applying to Peace Academy.

I certify that the information I provied on this form is true and accurate to the best of my knowledge.

Parent / Guardian Signature

Today's Date

Thanks for registering!

4620 S. Irvington Ave.

Tulsa, OK 74135

office@patulsa.org

918.627.1040

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