Kildonan Application

1

TheKildonan School

Application for Admission

Application Checklist:

� Completed Kildonan School Application� Teacher Recommendation Forms (2)� Educational and psychological testing given within the last three years (WISC/WAIS test must include sub-test scores; also include measures of achievement such as WJ-III or WIAT-II)�� 2IÀFLDO�6FKRRO�7UDQVFULSW� Recent Photograph� $50 Application Fee

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The Kildonan School admits students of any race, color, sex, and national or ethnic origin to all rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, nationality, ethnic origin, or any other characteristic protected by federal or state law in administration of its educational policies, admission policies, scholarships, athletic, and other school-administered programs.

THE KILDONAN SCHOOLApplication for Admission2

THE KILDONAN SCHOOLApplication for Admission 3

Applying for: � Full Boarding � Five-Day Boarding � Day � Elementary

Applying for Grade: _____ Current Grade: _____

Desired Date of Entrance: _____________________ � Male � Female

Applicant’s Name: ________________________________________________________________________ (FIRST) (MIDDLE) (LAST)

Preferred Name: _____________________________________ Date of Birth: _____________________________________

Address: ________________________________________________________________________ (STREET AND NUMBER)

________________________________________________________________________ (CITY) (STATE) (COUNTRY) (ZIP CODE)

Names/ages of sibling(s) (if applicable): _________________________________________________________ Is the applicant adopted? � Yes ��No Is there a history of dyslexia in the family? � Yes ��No

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Does the applicant have any allergies? � Yes ��No Have an EpiPen®? � Yes ��No ,I�\HV��SOHDVH�GHVFULEH��BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

How did you hear about Kildonan? _____________________________________________________________

STUDENT INFORMATION

Please attach a current photo

EDUCATIONAL HISTORY

Name of Current School: ___________________________________________ Grades Attended: _________

Address: ________________________________________________________________________

Does your child currently receive support services? � Yes ��No

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Family Information

Parent 1: ________________________________________________________________________________ (FIRST) (MIDDLE) (LAST)



Home Phone: ____________________________ Cell Phone: ______________________________ Work Phone: ____________________________ Fax Number: ______________________________

E-mail: ________________________________________________________________________

Occupation: ________________________________________________________________________

Post-Secondary Education and Degrees: ________________________________________________

Parent 2: ________________________________________________________________________________ (FIRST) (MIDDLE) (LAST)



Home Phone: ____________________________ Cell Phone: ______________________________ Work Phone: ____________________________ Fax Number: ______________________________ E-mail: ________________________________________________________________________

Occupation: ________________________________________________________________________

Post-Secondary Education and Degrees: ________________________________________________

Are you planning to apply for Financial Aid? � Yes ��No

Parents are � Married � Divorced � Separated

With whom does the applicant live? _______________________________________________________

Please note any special circumstances: _____________________________________________________

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__________________________________________________________________________________ STUDENT’S FULL NAME DATE

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To what extent were those services effective?

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Parent Questionnaire


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Is your child currently taking any prescription medications? � Yes � No� �,I�\RX�FKHFNHG�´<HVµ�SOHDVH�DWWDFK�D�OLVW�RI�DOO�FXUUHQW�SUHVFULSWLRQV�DQG�WKHLU�SXUSRVHV� Has your child displayed behavioral problems in school or at home? � Yes � No Does your child have a history of emotional problems or psychological counseling? � Yes � No � 'RHV�\RXU�FKLOG�KDYH�DQ\�KLVWRU\�RI�WKHIW��WREDFFR��DOFRKRO�DEXVH��LOOLFLW�GUXJ�XVH�� or prescription drug abuse? � Yes � No � �,I�\RX�FKHFNHG�´<HVµ�WR�DQ\�RI�WKH�DERYH�IRXU�TXHVWLRQV��SOHDVH�DWWDFK�D�GHWDLOHG�ZULWWHQ�� H[SODQDWLRQ�RI�WKH�SUREOHP�DQG�WKH�WUHDWPHQW�WKHUHRI��7KDQN�\RX�IRU�\RXU�FRRSHUDWLRQ�

This form was completed by:

_______________________________________________________________________ NAME/S (please print) _______________________________________________________________________ RELATIONSHIP TO STUDENT _______________________________________________________________________ SIGNATURE DATE _______________________________________________________________________ SIGNATURE DATE

KILDONAN RESERVES THE RIGHT TO WITHDRAW A STUDENT’S ACCEPTANCE OR TERMINATE 3/$&(0(17��,)�,1)250$7,21�3(57,1(17�72�<285�&+,/'·6�$33/,&$7,21�+$6�%((1�(,7+(5�

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Applicant Questionnaire

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* Elementary program applicants need only complete the check boxes (numbers 8-17).

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� History � Other: _____________________________

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Most recent book: _________________________________________

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Please answer the following questions thoughtfully.

Your answers will help us get to know you better and understand your writing style.


For students applying for Full Boarding or Five-Day Boarding Only:

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This form was completed by:

____________________________________________________________________________________ APPLICANT NAME (please print)

____________________________________________________________________________________ SIGNATURE DATE

Is this application in your own handwriting? � Yes � No

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____________________________________________________________________________________ NAME OF SCRIBE (please print) RELATIONSHIP TO STUDENT

____________________________________________________________________________________ SIGNATURE DATE


Teacher Reference Form

to be completed by a teacher��tutor, or school administrator

____________________________________________________________________________________ STUDENT’S FULL NAME DATE

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CONFIDENTIAL


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Attention/focus outstanding good fair of concern

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Relationship with peers outstanding good fair of concern

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Character outstanding good fair of concern

Please include any additional observations that you think would be helpful:

I recommend this student to The Kildonan School: � &RQÀGHQWO\�� With reservation � Not at all

____________________________________________________________________________________ NAME OF THE PERSON COMPLETING THIS FORM (please print) TITLE

____________________________________________________________________________________ SIGNATURE DATE

____________________________________________________________________________________ NAME OF SCHOOL CITY/STATE

____________________________________________________________________________________ SCHOOL TELEPHONE E-MAIL

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Math Teacher Reference Form

to be completed by the applicant’s current math teacher

____________________________________________________________________________________ STUDENT’S FULL NAME DATE

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CONFIDENTIAL


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Attention/focus outstanding good fair of concern

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Relationship with peers outstanding good fair of concern

Relationship with adults outstanding good fair of concern

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Character outstanding good fair of concern

Please include any additional observations that you think would be helpful:

I recommend this student to The Kildonan School: � &RQÀGHQWO\�� With reservation � Not at all

____________________________________________________________________________________ NAME OF THE PERSON COMPLETING THIS FORM (please print) TITLE

____________________________________________________________________________________ SIGNATURE DATE

____________________________________________________________________________________ NAME OF SCHOOL CITY/STATE

____________________________________________________________________________________ SCHOOL TELEPHONE E-MAIL

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SCHOOL TRANSCRIPT AND RECORDS RELEASE

Parent of Applicant�� &RPSOHWH�WKH�IRUP�EHORZ�DQG�VXEPLW�LW�WR�\RXU�FKLOG·V�FXUUHQW�VFKRRO��7UDQVFULSWV�0867�%(��

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___________________________________ Full name of applicant

____________________________________ ______________________________________ Parent (or guardian) name Signature

____________________________________ ______________________________________ Date Parent telephone number

School Registrar�� 7KH�DERYH�QDPHG�VWXGHQW�LV�DSSO\LQJ�IRU�DGPLVVLRQ�WR�7KH�.LOGRQDQ�6FKRRO��3OHDVH�

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The Kildonan School

425 Morse Hill Road

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CONFIDENTIAL


The Kildonan School Mission Statement

The mission of The Kildonan School is to empower students with dyslexia to reach their academ-LF� SRWHQWLDO� DQG� WR� HTXLS� WKHP� IRU� IXWXUH� VXFFHVV��2XU� WKUHHIROG�PLVVLRQ� UHPDLQV� FRQVLVWHQW��:H�VWULYH�WR�UHPHGLDWH�VNLOOV�LQ�UHDGLQJ��ZULWLQJ��DQG�VSHOOLQJ��WR�SURYLGH�LQWHOOHFWXDOO\�VWLPXODWLQJ�VXE-MHFW�PDWWHU�FRXUVHV�LQ�PDWKHPDWLFV��OLWHUDWXUH��VFLHQFH��DQG�VRFLDO�VWXGLHV��DQG�WR�IRVWHU�FRQÀGHQFH�

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The Kildonan SchoolEmpowering students with dyslexia since 1969

425 Morse Hill RoadAmenia, NY 12501

(845) 373-2012www.kildonan.org

Kildonan Application

Documents

Transcript of Kildonan Application