Print, Complete: 1 Application per student
S.O.U.L Academy “Students of Unlimited Learning”
Enrollment Application
 
Office use only 
______________ Application Fee:
 
School Year: _________________
 

Scholarship Amount: _________________

 
Date of Application ____________________ Applying for Grade _________ Returning/New R N Circle one
 
Applicant’s Name (Student) _________________________________________________________________ 
 
Address __________________________________________________________________________________ 
 
City________________________________________ State____________  Zip Code__________________
 
Home Phone ( )__________________________________ Date of Birth _______/____/_________
 
Male ______ Female ______                     Student’s Social Security Number ________- ________-_________
 
Parent Social Security Number _________-_______-___________ (Mckay/Step Up students/AAA only)
 
Previous school attended _______________________________________________________________
 
Mother’s Name _________________________________________________________________________
 
Home Address _________________________________________________________________________ 
If different from above
 
City________________________________________ State____________  Zip Code__________________
 
Home phone (______)_________________________ Cell Phone (_______)_____________________
If different from above
 
Occupation ______________________________________ Employer ______________________________
 
Work Phone (______)______________________________ Email __________________________________
 
 
Father’s Name ________________________________________________________________________
 
Home Address ________________________________________________________________________
If different from above
 
Home Phone (______)_________________________ Cell Phone (______)_______________________
If different from above
 
Occupation __________________________________ Employer _______________________________
 
Work Phone (______)______________________________ Email _______________________________
 
 

With whom does the student live? _____Both Parents ____Mother ____Father ____Guardian

 
Parents are: ____Married _____Separated ____Divorced ____Single
 

Personal Information

 
Has your child been referred for psychological or education assessment? Yes/No. If yes, please briefly
 
Describe: ______________________________________________________________________________
 
______________________________________________________________________________________
 
______________________________________________________________________________________
 
Please describe any special needs: ___________________________________________________________
 
Family Church Affiliation (if any): ______________________________________________________________
 
In what activities has the student’s participated in school? _______________________________________
 
___________________________________________________________________________________________
 
___________________________________________________________________________________________ 
 
What are the student’s hobbies, interests or activities outside school? ______________________________
 
____________________________________________________________________________________________
 
Family Information:
 
Please list the names and ages of other children in the family.
 
Name _______________________________ Age_____ School Attending ___________________________
 
Name _______________________________Age______ School Attending ___________________________
 
Name _______________________________Age______ School Attending ___________________________
 
Student Release Information:
 
Each child will be released only to a parent or a person named by the parent. Please list the person or person’s authorized by you to pick up your child.
 
Name ___________________________________  Phone (______)_______________________
 
Name ___________________________________  Phone (______)_______________________
 
Name ___________________________________  Phone (______)_______________________
 
*** Name of person (s) not authorized to pick up your child: _________________________________
 
_____________________________________________________________________________________
 
Publicity Authorization
 
S.O.U.L. Academy, Inc. anticipates using children’s picture and names for publicity and news stories. Please mark the appropriate information for your child.
 
_____ I do give permission to SA to use my child’s picture and name for publication purposes.
 
_____ I do not give permission to SA to use my child’s picture and name for publication purposes.
 
 

Emergency Contacts

Please list below the names and phone numbers of persons to contact if your child becomes ill at school and you cannot be reached.
 
Name __________________________________________ Phone (______) ________________________                               
 
Name __________________________________________ Phone (______) ________________________
 
Name __________________________________________ Phone (______) ________________________
 

Medical Diagnosis

Has your child ever received a mental health diagnosis; such as ADHD or Autism?   _____Yes _____No

Has your child been prescribed medication for a mental health diagnosis? If yes, please list medications

______________________________________________________________________________________

What is the diagnosis or prognosis? _________________________________________________________

Authorization for Medical Treatment of Minors
 
Name of Minor Date of Birth
 
Allergies, special conditions or medications: _________________________________________________
 
_________________________________________________________________________________________
 
 
I/We being the parents (s) or legal guardian (s) of the above-named minor do hereby appoint the faculty and staff of S.O.U.L. Academy to act on my/our behalf in authorizing unexpected medical, dental, hospitalization, and surgical care for the above-named minor during the period of my/our absence. This document shall be presented to a physician, dentist, or appropriate hospital representative at such a time as unexpected medical, dental, hospitalization or surgical care may be required.
 
Insurance company/Gov. Program _________________________________________________________
 
ID, group or contract number _____________________________________________________________
 
Family physician or pediatrician _______________________________ Phone (______)_______________
 
Physician’s Address______________________________________________________________________
 
City________________________________________ State____________  Zip Code__________________
 
Parent or Guardian Signature _____________________________________ Date ____________________
 
Parent or Guardian Signature _____________________________________ Date ____________________
 
Witness Signature ______________________________________________ Date ____________________
 
I hereby state that the information I have provided in this application is accurate and complete
 
Signature of Parent or Guardian ___________________________________ Date ____________________
 
S.O.U.L. Academy admits students of any race, color and national and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the Academy. It does not discriminate on the basis of race, color, disability, national or ethnic origin in administration of its educational policies, admissions policies and other school-administered programs.
 
 
This portion is for Scholarship and Payment information purposes. Please circle the tuition method you are using.
 
Step Up For Students
 
AAA Scholarship
 
McKay Scholarship
 
Private Paying Parent