Student Application

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Referral Information



Please enter only one email address in this field








Applicant Information


















Please only provide one number






Please only provide one number







Placement Information







Parent/Guardian and Financial Sponsor Information








Parent/Guardian 1 Information

If you enter a First Name, you must also enter a Last Name.


Must be valid email format "example@email.com" Leave blank if you don't know the email.





Please complete address even if same. Thank you!









If you enter a First Name, you must also enter a Last Name.


Must be a valid email format - example@email.com. Leave blank if you do not know the email address.







Parent/Guardian 2 Information

If you put in a First Name, you must also put in a Last Name


Must be a valid email format - "example@email.com". Leave blank if you do not know the email address.





Please complete address even if same. Thank you!










If you enter a First Name, you must also enter a Last Name.


Must be a valid email format - example@email.com. Leave blank if you do not know the email address.








Psychological History-Clinical: describe in detail any checked items
























Psychological History-Unusual Behaviors : Check all that apply
















Placement and Provider History











Must be a valid email format - example@email.com. Leave blank if you do not know the email address.





Must be a valid email format - example@email.com. Leave blank if you do not know the email address.













Must be a valid email format - example@email.com. Leave blank if you do not know the email address.








Page 6

Educational Information











School Information






Medical Information










Please be aware that if the student is taking: Lithium, Depakote, Tegretol, Geodon, or Topomax, they will be required to see our psychiatrist, Dr. Braunstein, for medication management. This may require periodic blood draws, which may incur payment.








If yes, Please ensure student’s orthodontist is listed on the release form. Student’s orthodontia plan will be put on hold while at Open Sky. We will coordinate with an are orthodontist to fix emergent issues, but cannot coordinate scheduled maintenance or cosmetic repair.











Contacts are not allowed. Please send 2 pair of glasses with hard cases.

Contacts are not allowed. Please send 2 pair of glasses with hard cases.
Does the Applicant Currently Have or Has Had the Following? Please check all that apply.
By NOT Checking a Box, you Acknowledge that the Condition DOES NOT Apply to the Applicant.

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If tetanus is greater than 5 years ago, applicant will need a booster.