Online Application for Admission

STUDENT INFORMATION

Name*

First Last

Date of Birth*

MM

DD

YYYY

Applying for Grade*

Program of Interest

Enrolling Start Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Resides With (please check all that apply)

Father
Mother
Stepfather
Stepmother
Guardian
Other

Primary Language*

Ethnicity

Present School*

Present Grade*

PARENT INFORMATION

Parent 1

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Occupation

Employer

Relationship Status:*

Single
Married
Separated
Divorced
Widow/Widower
Partnered

Parent 2

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Occupation

Employer

Relationship status:

Single
Married
Seperated
Divorced
Widow/Widower
Partnered

SCHOOL AND MEDICAL INFORMATION

Has the student ever had a psycho-educational assessment? (If yes, attach report below)*

Does the student have a current IEP or 504? (If yes, attach report below)*

Has the student ever received special services?*

Special services may include: counseling, treatment, tutoring, speech therapy, occupational therapy, etc.

If yes, please explain and attach report below:

Is there any medical or psychological history that may interfere with the student's ability to participate fully in the school's programs?*

If yes, please explain:

Has the student ever been suspended from school or involved with the judicial system?*

If yes, please explain:

ADDITIONAL INFORMATION

Is the student adopted?*

Who should receive correspondence regarding student?*

Who is financially responsible for the student?*

Has any relative attended Leelanau School?

If yes, state name, relationship to student, and years attended?

How Did You Learn About Leelanau:

REQUIRED ATTACHMENTS

If file size is too large to attach. Please email files separately to admissions@leelanau.org.

Photograph

Assessment Report

Transcripts

School Reports (IEP or 504 Plan)

Other Clinical Reports for Special Services

SIGNATURE AUTHORIZATION

We, the undersigned, understand that any information furnished in support of this application shall be complete and confidential, and shall not be disclosed to anyone, including the candidate and his/her family, except that the Director of Admissions may, for official purpose at his/her discretion, disclose any part or all thereof to such person or persons as he/she deems advisable. We further attest that all statements made herein, and on the Student’s and Parental/Guardian Statements are true and complete, and understand that any false statements, or disclosures could result in the dismissal of the applicant, if enrolled.

Signature of Parent or Guardian*

Date*

The Leelanau School adheres to a long standing policy of admitting students of any race, color, creed, religion, orientation, national or ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. The Leelanau School does not discriminate on the basis of race, color, creed, religion, orientation or national or ethnic origin in the administration of our educational policies, admissions policies, scholarship and loan programs, personnel practices or athletic and other school-administered programs

Domestic and International Student Application

STUDENT INFORMATION

PARENT INFORMATION

Parent 1

Parent 2

SCHOOL AND MEDICAL INFORMATION

ADDITIONAL INFORMATION

REQUIRED ATTACHMENTS

SIGNATURE AUTHORIZATION