San Blas Application

San Blas Homeschool Enrichment Application

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Parent Name *

First

Last

Email *

Phone

Where do you live? *

Student Name *

First

Last

Date of Birth *

Gender *

Male
Female

Enrollment level:

Nationality *

Language(s) Spoken at Home *

Reading Level (if known)

Grade *

Anticipated Start Date *

Please list any allergies your child has, including food, medications, insect, etc. If not applicable, please write "N/A." *

Please describe your child's schooling history. Include homeschooling, public, and private schooling. Also, please list any reading or writing curriculum you have used, if homeschooled. *

Does your child have any of the following: *

ADD
ADHD
Autistic/Asperger's/PDD
Cognitive Disability
Dysgraphia/Writing Problem
Dyslexia/Reading Problem
Emotional Disability
Gifted
Learning Disability
Physical Disability
Speech/Language Disability
Traumatic Brain Injury
Other
None

Has your child had any problems in the following areas? *

Attention/concentration
Avoidance of school work
Loses place/skips lines
Low self-esteem
Motivation/behavior
Overly active
Poor memory
Reading comprehension
Reversals of letters or words
Slow work
Spelling
Writing
Works too hard
None

Please list any past or current help, training, or tutoring utilized for the above concerns. If not applicable, please write "N/A." *

Please tell us about your child's reading habits. How often does your child read? What genres has your child most enjoyed to date? What books does your child choose when left to their own devices? Do they listen to audiobooks? *

Does your child use electronics? (Check all that apply) *

Own their own phone
Uses parent's phone
Has their own Ipad or Tablet
Has their own computer

If your child uses electronics, please check all that apply. *

Only for school work
For school and pleasure

Does your child play video games? *

Yes
No

What does your child like to do for fun? Please tell us about your child's hobbies, interests, and passions.

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