Application page 1

THE NEXUS SCHOOL

2801 Woodland Rd. Roslyn, PA 19001

Telephone: 215-657-2434

E-mail:

Application for Admission

Date ______Application for School Year: ______

Applicant’s Legal Name - Last FirstMiddle

(If student has a double or hyphenated last name, please indicate preferred order.)

Preferred NameDate of BirthPlace of Birth

Gender: Female  Male Current Grade:

Family Information

Parent/Guardian * / Parent/Guardian *

Name

/

Name

Street Address

/

Street Address

City, State, Zip Code
Home Telephone / City, State, Zip Code

Home Telephone

E mail / E mail
Employer/Position / Employer/Position
Work Telephone /

Work Telephone

* All school mailings will be sent to both parents/guardians unless we are notified in writing otherwise. Please attach information regarding any other parents/guardians of the Applicant.

• Please list names, birth dates and schools of other children in the Applicant's family/household:

Please list names and ages of other individuals who reside in the household with the Applicant.

Current School Information

Current SchoolDates of Attendance
School Address Street, City, State, Zip CodeTelephone
Current Teacher(s) Principal

School(s) Previously Attended (Names & Dates)

Additional Family Information

What is your child’s primary language? What languages are spoken in your home?

If parents/guardians are not married, or are separated or divorced, with whom does the child live?

Who is financially responsible for the child’s education?

If other than parents/guardians, please explain.

Student Description - Mandatory
  1. Please discuss on separate pages your goals for your child’s education and expectations you have for his/her school.

Discuss or describe:

  • Why your child’s current educational program is, or is not, meeting your child’s needs;
  • How well your child relates to other family members and classmates;
  1. Does your child have any compulsive or obsessive behaviors? Please describe.
  1. Does your child have any aggressive/tantrum behaviors? Please describe.
  1. Describe your child’s ability to attend to instruction/ Do attending issues change based on activity/environment/ and teacher-child ratio
  1. Does your child have any anxiety/rigidity issues? Please describe.
  1. Does your child have particular transition issues? Please describe.
  1. Would your child attempt to wander away from school premises?
  1. Is your child toilet trained? Partially trained? Please describe.
  1. Please list on a separate sheet any allergies - environmental and food - that the Applicant has and include type of reaction he/she experiences.
  1. Are there any medical, emotional/behavioral, physical or other issues that might interfere with his/her optimal school adjustment that you have not already described?

Also, please provide copies of all reports that relate to your child from psychologists, psychiatrists, neurologists, behavioral specialists, occupational therapists, and speech and language pathologists, and IEPs produced in the past 24 months. You may also provide other pertinent information that will help us accurately evaluate your child. Please list below each report writer’s name and phone number, in case TNS needs clarification or additional information relating to any submitted report.

Teacher References

This reference is due after the child has been determined to be a “fit” for TNS and before the formal acceptance agreement with your school district.

Please note the name(s) and address(es) of teacher(s) completing the Reference Form:

Name(s)
Name(s) and Address(es) of School(s)______

Telephone Number(s)______

Behavioral Consultant Reference

This form is due prior to the child’s visitation at TNS.

Please note the name and address of behavioral consultant completing the Reference Form:

Name
Address

Telephone Number(s)

To The Parent/Guardian:

Thank you for your interest in The Nexus School. Your signature below grants TNS permission to secure further information pertaining to the child’s formal acceptance at TNS.

I/We understand that all Admission information is confidential and will be held securely for 2 years and then shredded if my child is not admitted.

I/We understand that all information regarding a candidate's application for admission to The Nexus School will be treated with complete confidentiality. Only authorized TNS personnel have access to this information, and then only to the extent that the information is relevant to The Nexus School admission and placement decisions. Information received within the scope of this policy is not disclosed to the applicant or to the applicant's family.

I/We hereby state that the information contained herein is true and complete. I/We have not knowingly or intentionally omitted any pertinent or requested information regarding my/our child's academic, medical, or behavioral history.

Signature of Parent/GuardianDate
Signature of Parent/GuardianDate

THE NEXUS SCHOOL

2801 Woodland Road • Roslyn, PA 19001

Telephone: 215-657-2434

Email:

Current School Report Request

To the Parent/Guardian:

Please complete this section, sign below, and give this to your child’s current school administrator.

Applicant Name Applying for Grade
Current SchoolCurrent Grade

I give permission for my child’s school records to be sent to The Nexus School.

I understand that all references pertaining to this application are confidential.

Signature of Parent/GuardianDate

Dear Colleague:

The child indicated above has applied for admission to The Nexus School. We are requesting a copy of the student’s report cards, transcripts or school progress reports. We would also greatly appreciate any information you might share about her/his academic, social, and emotional development. We do not require standardized tests, but if you have test results available they would be helpful to us, as would any other material relevant to the child’s readiness for the grade to which she/he is applying. Please see the attached TNS Statement of Confidentiality. You may use the reverse side of this sheet for your remarks or attach a separate page. We would particularly appreciate comments on the following:

For All Applicants

How long have you known this student?

Has this student been suspended or expelled for any reason during the last three years?  Yes  No If yes, please give full details, including date, nature of incident, and nature of discipline. Suspension or expulsion will not necessarily bar admission.

For Pre-Kindergarten through Grade 2
• Class size and age range of group / • Number of hours and days per week child is in class
• Social and emotional adjustment / • Motor Coordination (gross and fine)
• Curiosity / • General health
• Attention span
For Grades 3-8
• Length of time enrolled in present school / • Class size
• Academic progress / • Social and emotional adjustment
Basic skills, strengths and weaknesses / Relationship to peers
Attitude toward learning / Self-confidence
Ability to concentrate and follow through / • Special interests

This completed form with any attached narrative, along with a copy of the child’s report cards, and transcripts or school progress

reports, should be returned to the address selected by the parents at the top of this form as soon as possible. Thank you

for your assistance.

School Administrator’s Signature (please print name above or beside signature)Date

School AddressTelephone Number

The above form will be sent after a formal acceptance has been reached between TNS and the SD.

The Nexus School Statement of Confidentiality

All information regarding a candidate's application for admission to The Nexus School will be treated with complete confidentiality. Only authorized The Nexus School personnel have access to this information, and then only to the extent that the information is relevant to The Nexus School admission and placement decisions. Information received within the scope of this policy is not disclosed to the applicant or to the applicant's family.