The Joseph Sams School

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

The Joseph Sams School Application Checklist

Please enclose all requested items with the application form

Please submit the following documents via email to Leah Shaw at leahshaw@josephsamsschool.org.

Recent photograph of child
Copy of current Psychological, Neurological, Speech, and Language Reports

If applicable:

Most recent Progress Report
Most recent Behavioral Assessment
Current IEP
Current Eligibility from Public School System

After receipt of required documents, The Joseph Sams School Staff will contact you to verify receipt and schedule an assessment.

Application Fee

$300.00

Applicant Information

Applicant Last Name: *

Applicant First Name: *

Applicant Middle Name: *

Preferred Name: *

Birthdate: *

Age: *

Sex: *

Address: *

City: *

State: *

Zip Code: *

Telephone: *

Ethnicity: *

Primary Language: *

Current School District: *

Current School: *

Present Grade: *

Primary Diagnosis: *

Requested enrollment date (month): *

Requested enrollment date (year): *

Family Information

MOTHER'S INFORMATION

Mother’s Name: *

First and Last

Mother's Address: *

City: *

State: *

Zip Code: *

Home Phone: *

Cell Phone: *

Work Phone: *

Email: *

Employer: *

Occupation: *

Employer Address: *

City: *

State: *

Zip Code: *

Marital Status: *

Talents, Resources, Interests, Professional Skills: *

What talents, resources, interests or professional skills would you as a parent/guardian be willing to share with The Joseph Sams School? Please describe.

FATHER'S INFORMATION

Father’s Name: *

First and Last

Father's Address: *

City: *

State: *

Zip Code: *

Home Phone: *

Cell Phone: *

Work Phone: *

Email: *

Employer: *

Occupation: *

Employer Address: *

City: *

State: *

Zip Code: *

Marital Status: *

Talents, Resources, Interests, Professional Skills: *

What talents, resources, interests or professional skills would you as a parent/guardian be willing to share with The Joseph Sams School? Please describe.

If the child does not live with the parents in one household, please complete the following

The student also lives with:

Other (please explain):

Name:

Home Phone:

Cell Phone:

I Give Permission:

I give The Joseph Sams School permission to share Applicant’s information with the above-mentioned person.

The student also lives with:

Other (please explain):

Name:

Home Phone:

Cell Phone:

I Give Permission:

I give The Joseph Sams School permission to share Applicant’s information with the above-mentioned person.

Applicant resides with: *

Other:

Person responsible for fees: *

Other:

Send official correspondence to: *

Other:

Permission to Provide Records and Reports

Does The Joseph Sams School have permission to provide records and reports to the parent not living in the home?

This includes permission to provide reports for the following;
Medical History and Information
Seizure Information
Educational History
Speech Therapy Information
Motor Skills Information
Behavioral Information
Motivators

Permission to Provide Records and Reports: *

Medical History and Information

DIAGNOSIS:
Please list all the applicant’s diagnoses, and the dates they were made. Please include health related as well as developmental diagnoses. Please attach supporting documentation to the diagnosis if available.

Diagnosis:

Diagnosis Date:

Diagnosis:

Diagnosis Date:

INJURIES/ILLNESSES:
Please list any significant past injuries, surgeries or extended illnesses, and the dates they occurred (Including tubes and removal of tonsils and adenoids).

Event:

Event Date:

Event:

Event Date:

Is the applicant currently medically stable? *

If no, please explain:

Is the applicant’s vision within normal limits? *

If no, please explain:

Is the applicant’s hearing within normal limits? *

If no, please explain:

ALLERGIES:
Please list any allergies from which the Applicant suffers. Please include all allergies (environmental, food and medication). Please attach an additional sheet if necessary.

Allergy:

Symptoms:

Treatment:

SEIZURE INFORMATION:
If your child has a history of seizures, please describe what a “typical” seizure looks like, how long it may last, etc. Please know that it is a JSS policy to call 911 for seizures lasting 5 or more minutes.

Describe Seizures:

Educational History

CURRENT SCHOOL & SERVICES

Name of School: *

Grade/ Class Type: *

Name of Principal/Administrator: *

Name of Teacher: *

Type of School: *

Services Provided by School: *

Other:

Has there been any difficulty with the Applicant’s behavior in a school situation? *

Current Therapies

Please list all therapies the applicant is currently enrolled in (speech, physical, occupational, etc).

Type of Therapy:

Frequency:

Start Date:

Therapist’s Name:

Therapist Phone Number:

Type of Therapy:

Frequency:

Start Date:

Therapist’s Name:

Therapist Phone Number:

Parent Expectations

Please state your Vision Statement for your child:

Please describe your Short Term Goals for your child:

Please describe your Long Term Goals for your child:

Please describe how you would like The Joseph Sams School to help you achieve these goals:

Please describe your concerns with your child’s current placement:

How did you learn about The Joseph Sams School?

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Contact Number: *

Email: *

A receipt will be emailed to this address.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *