STUDENT ENROLLMENT
APPLICATION

Thank you for your interest in applying for enrollment! Filling out an online student application is the first step to getting your K - 8th grader enrolled in our Academy program. We require a $250.00 registration fee to officially submit an Academy Student Enrollment Application. You will be directed to another page once you fill out and submit the form below. After we receive and review your submitted information, one of our staff members will be in contact with you to discuss the next steps and answer your questions.

Student Name

First Name

Last Name

Message

Date of Birth

School Currently Attending

Please tell us what public, private, home, or other school the student is currently attending.

Grade?

Parent/Legal Guardian Information

Parent Name

Must be over 21

First Name

Last Name

Phone

(###)

###

####

Insurance Information

Insurance Carrier

*BCBS NE or NE MEDICAID ONLY*

Member Name

ID #

EDUCATION HISTORY INFORMATION

Student currently has an IEP or 504 plan

Please check the box if the student currently has been given an IEP (Individual Education Plan)

IEP

504 Plan

Not Sure

Has your child received previous interventions and/or services?

Has your child been evaluated? If yes, please explain.

Please share your child’s strengths and interests.

Please share your concerns, classroom teacher/school concerns.

Do you have concerns with your child’s language/speech? Do they or have they previously received speech services?

Please provide any additional information that will help us to support your child.

I acknowledge that by submitting this student application it does not guarantee an enrollment in the Simplistic Learning Academy Program. I understand that this is simply a preliminary application for my student to be considered for enrollment in the up coming semester/year.

Please check the box if you agree and acknowledge.

YES

You will be asked to pay the one-time registration fee on the following page

HAVE QUESTIONS?

ENROLLMENT PAGE CONTACT FORM

Name

First Name

Last Name

Phone

(###)

###

####

Message

Financial Assistance

LET US HELP

FAQ's Page

STUDENT ENROLLMENTAPPLICATION

HAVE QUESTIONS?

STUDENT ENROLLMENT
APPLICATION