ADMISSIONS PRE-APPLICATION Northwest Academy
Student Personal Information
Student's Full Legal Name :
  First Middle Last
Date of Birth Place of Birth
Gender:
    Male Female Citizenship Height Weight  
Hair Color Eye Color Identifying Marks
Race/Ethnicity If Native American, Tribal Affiliation
Student’s Religious Preference Current Grade Level
Address of student's primary residence
City State Zip
Address of student's most recent residence
City State Zip
Lived with whom Phone
Was student adopted? Yes No Age at adoption
Parent/Guardian Information
In the case of a divorce or a legal guardianship, please attach a copy of the court documents assigning custody of the student.
Mother's Full Legal Name :
  First Middle Last
Custody: Yes Joint No
Address
Marital Status:
  Married Single Separated Divorced  
City State Zip
Home Phone Cell Phone
Fax E-mail
Employer Occupation
Business Address
City State Zip
Business Phone Business Fax
Father's Full Legal Name :
  First Middle Last
Custody: Yes Joint No
Marital Status:
  Married Single Separated Divorced  
Address
City State Zip
Home Phone Cell Phone
Fax E-mail
Employer Occupation
Business Address
City State Zip
Business Phone Business Fax
Business Email
 
Stepmother's Full Legal Name :
  First Middle Last
Custody: Yes Joint No
Address
City State Zip
Home Phone Cell Phone
Fax E-mail
 
StepFather's Full Legal Name :
  First Middle Last
Custody: Yes Joint No
Address
City State Zip
Home Phone Cell Phone
Fax E-mail
Emergency Contact Information
In case of emergency and parents cannot be reached, please notify:
Name #1 Relationship
Address
City State Zip
Home Phone Work Phone
I/We hereby authorize IES to contact the above emergency contacts if necessary and to disclose any information regarding the above named student to such emergency contacts that would have been released to me as a parent.
Parent/Guardian Name Date
Signature
Out-of-Home Placement (if applicable)

Please list placements outside of the home: boarding schools, foster homes, psychiatric hospitalizations, etc.

Name
Consulting Professional
Address
City State Zip
Telephone Fax
Email
Dates of Placement: From To
Reason for Placement and Subsequent Departure

I/We hereby authorize the above consulting professional(s) to release information regarding the above named student to IES.

Parent/Guardian Name Date
Signature
Professionals Who Are Assisting the Student
Please list all educational consultants, psychiatrists, psychologists, and counselors/therapists who are currently working with the student.
Name
Dates of Service: From To
Address
City State Zip
Telephone Fax
Email
Nature of Service
Name
Dates of Service: From To
Address
City State Zip
Telephone Fax
Email
Nature of Service
How did you first hear about us

If you were referred by a specific person, please provide the name of the person who referred you and their relationship to you or your child, e.g. educational consultant, therapist, school counselor, friend of family, IES parent, etc.

Name of Referral Source Relationship
Address
City State Email
Telephone Fax Email
 
Member Of
Northwest Association of Accredited Schools
National Association of Therapeutic Schools and Programs (NATSAP)
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Northwest Academy is owned and operated by a subsidiary of Universal Health Services,
one of the nation's largest hospital management companies. HIPPA Notice of Privacy Practices