Springstone Application Form Step 1 of 2 50% THE SPRINGSTONE SCHOOLSTUDENT INFORMATIONStudent Name(Required) First Last Pronouns(Required)Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Diagnosis (if any)(Required)Current School(Required)Current Grade(Required)FAMILY INFORMATIONParent 1(Required) First Name Last Name Occupation/Employer(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Email Address(Required) Enter Email Confirm Email Your Phone(Required)Alt. PhoneParent 2 First Name Last Name Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Email Address(Required) Enter Email Confirm Email Your Phone(Required)Alt. Phone(Required)Siblings(Required)If none, write NAFeel free to include a photograph of your student(Required) Drop files here or Select files Max. file size: 50 MB. How did you hear about Springstone?(Required)What school year and grade level are you seeking to enroll your child with Springstone?(Required)Past and Present Services (fill those that apply)(Required) Occ. Therapy Speech and Language Psychologist Tutor Social Skills Select AllPast and Present Servies Details(Required)ServicesProviderDates of Service Add RemovePlease list up to three professionals who are working with your child at the present time whom we may contact(Required)NameTitlePhoneEmail Addres Add RemoveMedical history(Required)Past and present medications(Required) Springstone QuestionnairePlease check the appropriate answer. 1. Is your child able to recognize body language cues that accompany conversation?(Required) Yes No 2. Does your child's body language match what they say?(Required) Yes No 3. Is your child able to join a group of peers easily?(Required) Yes No 4. Is your child able to stay on the topic of a conversation?(Required) Yes No 5. Is your child able to take turns in a conversation?(Required) Yes No 6. Does your child demonstrate a broad range of interests?(Required) Yes No 7. When requested to stop, is your child able to stop what they are doing?(Required) Yes No 8. Is your child able to calm themselves down when upset?(Required) Yes No 9. When frustrated, can your child calm down within 5 minutes?(Required) Yes No 10. Do you need to physically restrain your child when they are upset?(Required) Yes No 11. Is your child able to control their anger appropriately?(Required) Yes No 12. Does your child associate with children their own age?(Required) Yes No 13. Does your child have an established group of friends at school?(Required) Yes No 14. Does your child connect with adults more than peers?(Required) Yes No 15. Can your child type on a word document?(Required) Yes No 16. Is your child able to use the Internet appropriately?(Required) Yes No 17. Is your child able to transition from task to task easily?(Required) Yes No 18. Is your child able to attend to a task for 20 minutes?(Required) Yes No 19. Does your child require frequent repetitions of instructions?(Required) Yes No 20. Does your child have, or have they ever had a Behavior Support Plan (BSP)?(Required) Yes No 20. Does your child have, or have they ever had a Behavior Support Plan (BSP)?(Required) Yes No 21. Is your child overly sensitive to touch, sound, smells, etc?(Required) Yes No 22. Can your child walk up to 3 miles without support?(Required) Yes No 23. Can your child independently tell a merchant what they would like to order?(Required) Yes No 24. Can your child independently make small purchases from a merchant?(Required) Yes No 25. Has your child ever had a one to one aide in classroom settings or at home?(Required) Yes No 26. Does your child currently or have they in the past received mental health services privately or through their home district?(Required) Yes No 27. Does your child know that they have a disability?(Required) Yes No Please list your child's strengths(Required)Please identify your child's interests(Required)Describe what your child looks like when they are happy -- what behaviors do they exhibit?(Required)What behaviors do they exhibit when they are frustrated?(Required)Does your child have any extreme fears or obsessions? Describe them.(Required)Describe your child's current performance in school:(Required)How did your child fair during distance learning?(Required)Are your child's needs being met in their current school program?(Required)How does your child respond to direct feedback, support, and guidance from an adult?(Required)Please describe why you are currently seeking Springstone's services(Required)Please also send in your child's current IEP, recent grades and school records, and reports from formal assessments (Occupational Therapy, Speech and Language, Neuropsychological, etc.).(Required)If your files are larger than this form allows, feel free to email them to info@thespringstoneschool.org Drop files here or Select files Max. file size: 50 MB. Pay $150 application feeYour application is not considered complete until your application fee has been received. Pay the application fee hereRelease of InformationI(Required) Full Name I hereby authorize The Springstone School administrative staff to obtain confidential student information for the followingStudent Name(Required) First Last I understand that the staff may receive copies of any psychological, academic, medical or other reports relevant to my child and their education.Signature of Parent/Guardian(Required)Date(Required) MM slash DD slash YYYY Non-DiscriminationThe Springstone School admits students of any race, color, and national or ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at our school and does not discriminate on the basis of race, color, and national or ethnic origin in administration of our educational policies, admissions policies, scholarship and loan programs, and athletic and other school-administered programs. Δ
