Are the parents married? YES NO

Does this child have any siblings? YES NO

What would you like for your child to get out of his experience at our school?

Please describe anything else that might help us in planning your child's stay with us at Fieldstone Academy:

Please indicate that you have read and understand our Private Information Policy

By submitting this form I attest that the above information is true to the best of my knowledge. I also authorize Fieldstone Academy to release any information required to process my claims. I understand that any false or missing information on this application can result in my child being returned to me at my expense and that any deposits or payments made to Fieldstone Academy would then be forfeit. I have read and understand the above