Admission_Application-The_ Lowell

		THE LOWELL SCHOOL
		www.thelowellschool.com
203-05 32nd Avenue			142-45 58th Road
Bayside, New York 11361			Flushing, New York 11355
718-352-2100			718-445-4222
Elementary & Middle School			High School
	APPLICATION FOR ADMISSION
Date: ___________________
Child’s Name _______________________________________________________			Date of Birth ____________________________
(Last)	(First)	(Middle)
Male ____________	Female ____________

Address: ___________________________________________________________________________________________________

(Street)	(City)			(Zip)
Telephone: (_______) _____________________________
Social Security Number: __________________________
Current School: __________________________	Present Grade: ____________________			Please attach a
Current School: __________________________	Present Grade: ____________________
School Contact Person: ____________________	Phone Number: (	)______________		recent photograph of
Region/District: __________________________				your child
				your child
High School Credits Earned: ________________
Please list all schools attended:
Please list all schools attended:
School	City & State		Dates of Attendance
____________________________________	_________________		____________________
____________________________________	_________________		____________________
____________________________________	_________________		____________________
____________________________________	_________________		____________________

					Parent Information
__Ms.	__Mrs.	__Mr.		__ Dr.		__ Ms. __Mrs. __Mr. __Dr.
Name __________________________________________						Name: _______________________________________
	(Last)			(First)	(Middle)	(Last)		(First)	(Middle)
Home Address: ________________________________						Home Address: ________________________________
City, State, Zip: ________________________________						City, State, Zip: ________________________________
Home Telephone: (			) _________________________			Home Telephone: (		) _________________________
Work Telephone: (			) _________________________			Work Telephone: (		) __________________________
Cell Phone: (		) _____________________________				Cell Phone: (	) ______________________________
E-Mail Address: ______________________________						E-Mail Address: _______________________________
Occupation: __________________________________						Occupation: ___________________________________
Employer’s Name: _____________________________						Employer’s Name: ______________________________

If your child does not live with both parents in one household, please answer the following:

Are parents:

_____ Separated

_____ Divorced

_____ Single

Who is the legal guardian? ______________________________________________________________________________________

With which parent does the child live? ____________________________________________________________________________

Was your child adopted? _______________ If so, at what age? __________________________

List all people living in your household:
Name	Relationship to child	Age
___________________________________	________________________	_______
___________________________________	________________________	_______
___________________________________	________________________	_______
___________________________________	________________________	_______

List names and ages of any brothers or sisters living outside of the home:

Name	Relationship to child	Age
___________________________________	_______________________	________
___________________________________	_______________________	________
___________________________________	_______________________	________

Please tell us about your child:

Strengths: ___________________________________________________________________________________________________

____________________________________________________________________________________________________________

Study and work habits: _________________________________________________________________________________________

____________________________________________________________________________________________________________

What poses the greatest difficulty for your child? (academic/social)______________________________________________________

____________________________________________________________________________________________________________

Please describe your child’s non-academic special interests and abilities: _________________________________________________

____________________________________________________________________________________________________________

Has your child had any special physical, emotional or health problems? _____ Yes

_____ No

If so, please explain: __________________________________________________________________________________________

___________________________________________________________________________________________________________

Is your child taking medication? ________________________________
If so, please specify:
Name of Medication	Dosage	Time(s) of Day
_______________________________________	_________	_________________
_______________________________________	_________	_________________
_______________________________________	_________	_________________

What are your expectations upon your son’s/daughter’s High School graduation? (High School applicants only) __________________

____________________________________________________________________________________________________________

How did you find out about Lowell? ______________________________________________________________________________

____________________________________________________________________________________________________________

Have you ever applied to Lowell in the past?

_____ No

_____ Yes

If yes, when? _____________________

Is there any other information that you think would be relevant? ________________________________________________________

____________________________________________________________________________________________________________

Please enclose a nonrefundable application fee of $50.00 payable to The Lowell School

Please return this application with the application fee to:

Elementary/Middle School	High School
Ruth Joseph	Rona Wasserman
Clinical Coordinator	Clinical Coordinator
The Lowell School	The Lowell School
203-05 32nd Avenue	142-45 58th Road
Bayside New York 11361	Flushing, New York 11355
rjoseph@thelowellschool.com	rwasserman@thelowellschool.com

(The fee is waived for funded applicants.)

IMPORTANT: PLEASE FILL OUT THE RELEASE FORM ON THE BACK OF THIS

APPLICATION

FOR SCHOOL USE ONLY
Date application received __________	Application fee received __________
Date of check __________	Check # __________	Other ___________________________________________

The Lowell School does not discriminate on the basis of race, color, religion, sexual orientation, national or ethnic origin in administration of its admissions policies, educational policies, and athletic and other school-administered programs.

THE LOWELL SCHOOL

RELEASE FORM

Child’s Name: ____________________________________________________			Date of Birth: __________________
(Last)	(First)	(Middle)

I give The Lowell School permission to contact my child’s school, outside agencies or any professional(s) currently working with my child.

NAME	RELATIONSHIP TO CHILD	PHONE
_____________________________	______________________________	__________________
_____________________________	______________________________	__________________
_____________________________	______________________________	__________________
_____________________________	______________________________	__________________
_____________________________	______________________________	__________________
_____________________________	______________________________	__________________

I understand that admissions questionnaires and any other reports provided by teachers or therapists to The Lowell School as part of the admissions process will be confidential and will not be made available to parents or released to third parties without the express written consent of the person who prepared the report.

Parent’s Name: (Please print) __________________________________________________________________________________

Parent’s Signature: ___________________________________________________________________________________________

Date: ____________________________________________