Application Form | The Lionheart School

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Personal Information

Please complete the following form in its entirety, so that we may begin your child's admission here at The Lionheart School.

If you find that the online form is not working properly, please download our Fillable PDF by Clicking Here

Date of Application: 03/26/2023

Last Name

First Name

Preferred Name

Date of Birth

Current Age

School Year Applying for

Gender

Male Female

Are both parents living? *

Yes No

Divorced?

Yes No

Separated?

Yes No

Home Address

City

State

Zip

Contact Phone

Siblings Info

Do they have any siblings? *

Yes No

Medical Information

Child's Pediatrician

Pediatrician's Address

Pediatrician's Phone

Child's Psychologist

Psychologist's Address

Psychologist's Phone

Child's Counselor

Counselor's Address

Counselor's Phone

Has your child been seen by a developmental pediatrician or neurologist?

Yes No

Does your child have any medical conditions?

Is your child currently taking any medications?

Yes No

Is your child independent in the bathroom for all his/her needs?

Yes No

Please list any known allergies

Has your child ever had seizures?

Yes No

Is your child on a special diet?

Yes No

Therapeutic Services

Has your child been seen by any Therapists?

Yes No

Does your child use any augmentative communication systems?

Yes No

Educational History

Is your child currently enrolled at another school?

Yes No

Are you eligible for SB-10 funds?

Yes No

Are you eligible for HB-1133 funds?

Yes No

Do you receive the Katie Beckett Deeming Waiver?

Yes No

Do you receive the NOW Waiver?

Yes No

What are you looking for in a facility based program for your child?

If applicable, describe your child's reading level, decoding skills, fluency, comprehension, and phonemic awareness

If applicable, describe your child's math level, understanding of basic concepts, rote skills

Social Emotional History

Please describe how your child interacts with you.

Please describe how your child interacts with siblings.

Please describe how your child interacts with peers.

What are your child's favorite activities/topics of interest?

Describe what happens when your child is upset. What do you typically see? (kicking, biting, hurts self/others, withdrawn)

What does your child do to calm him/herself?

How long does it take your child to

Does your child exhibit impulsive or aggressive behavior? If yes, please describe.

Is your child supported by a behavior plan? If yes, please describe.

Does your child exhibit anxiety? If yes, please describe.

Please describe how your child makes transitions between people, activities, or environments (include level of independence during transitions, need for transitional objects, or advance preparation about schedule changes)

Other

Please provide any assessments made by outside professionals, and school progress reports.

Procedures and Policies for application to Lionheart

Lionheart school has a rolling admissions policy. Applications will be accepted and admission to the school will be considered when the following items below are complete:

Parent(s) of applicant have visited the school.
Lionheart has received a completed application.
Lionheart has received a non-refundable processing fee of $100.
Lionheart has received a Psychological Evaluation (required). If there are no comprehensive psychological reports
from the past three years, Lionheart reserves the right to ask an applicant to acquire one.
**Lionheart has received a current picture of applicant.
Lionheart welcomes other assessment reports from additional therapists and/or most recent school/teacher.
Applicant has met with the Head of School and Head of Therapeutic Services and completed a classroom visit.
Lionheart reserves the right to ask for additional visits before making a determination regarding the applicantʼs admission.

Once all items are received from applicant, the review process will begin. Lionheart professionals and outside consultants will help determine if your child is an appropriate fit for Lionheart and whether Lionheart can meet your child’s needs. If admitted, parents are asked to commit to enrollment for the entirety of the following academic year.

Lionheart will notify parents of acceptance into the program. Parents will then be required to send in the tuition deposit of $2,800 (non-refundable) within 10 days to secure their child’s placement into the program.

Notice of Nondiscriminatory Policy

The Lionheart School, Inc., admits students of any race, creed, or national and ethnic origin to all the rights and privileges, programs and activities generally accorded and made available to students at the school. It does not discriminate on the basis of race, creed, color, or national and ethnic origin in administration of its educational policies, admissions policies, or other school-administered programs.

I certify that the information contained in this application is complete and accurate to the best of my knowledge. By clicking the accept button below and typing your name, you are agreeing to a digital signature.

I agree

Type your name for Signature

03/26/2023