Fieldstone Academy Application

This application gives us some of the basic information we need to know about your student. The most important part of this is your contact information. We will need to talk on the phone eventually, but this will get us started.

By filling out this application, you are not committing to anything other than a conversation about your child. If your student is accepted, we will request additional information, more formal paperwork and verification, including transcripts, immunization records, insurance information, etc.

For now, let’s talk about your student…

Student Information

First Name (required)

Last Name (required)

Date of Birth (required)

Country of Citizenship

Current Grade Level

Street Address

City

Zip

Parent/Guardian Information

Primary Guardian First Name (required)

Primary Guardian Last Name (required)

Email (required)

Best Phone Number

Other Phone Number

Street Address (if different than student)

City

Zip

Secondary Guardian First Name

Secondary Guardian Last Name

Email (if applicable)

Best Phone Number

Other Phone Number

Street Address (if different)

City

Zip

Current School Information

School Name

School Fax Number

Counselor Name (if applicable)

School Phone Number

Other Information

Please describe, in your own words, your student's academic strengths and weaknesses, include GPA if available, test scores if available:

What does your student enjoy doing outside of school? Hobbies, extracurricular activities, etc.

Does your student have any history of illegal drug use, including alcohol and nicotine? If so, please explain and include length and severity of use:

Is your student sexually active? If so, please explain:

Has your student ever attempted suicide, threatened suicide, or been hospitalized for suicidal tendencies? If so, please explain:

Please list any medications your student is taking, also include any food allergies we should be aware of:

Is there anything else we should know about your student's behavior or situation?