Online Application

Hope Creek Academy-Online Application

Date of Application *

Child's Name *

First

Middle

Last

Preferred Name

Date of Birth (xx/xx/xxxx) *

Student's Current Grade Level *

Anticipated School Year *

NOTICE OF NONDISCRIMINATORY POLICY AS TO STUDENTS: Hope Creek Academy admits students of any race, color, national and ethnic origin, or sexual orientation, to all rights, privileges, programs, and activities, generally made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin, or sexual orientation in administration of its educational and admissions polices, scholarship programs, and other school-administered programs.

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Confirm Email

Address *

Street #, Street Name, City, State, ZIP Code

Phone Number- Home *

(xxx) xxx-xxxx

Phone Number- Mobile

(xxx) xxx-xxxx Do not provide if duplicate.

Phone Number- Work

(xxx) xxx-xxxx Do not provide if duplicate.

Relationship to Student *

Interests/Hobbies *

Other Household Residents *

Please provide a comprehensive list of other household residents: name, age, and relationship to student.

Parent/Guardian Name

First

Last

For other parent/guardian, if needed

Parent/Guardian Email

Confirm Email

For other parent/guardian, if needed

Address

Street #, Street Name, City, State, ZIP Code. For other parent/guardian, if needed

Phone Number- Home

(xxx) xxx-xxxx For other parent/guardian, if needed

Phone Number- Mobile

(xxx) xxx-xxxx Do not provide if duplicate. For other parent/guardian, if needed

Phone Number- Work

(xxx) xxx-xxxx Do not provide if duplicate. For other parent/guardian, if needed

Relationship to Student

For other parent/guardian, if needed

Interests/Hobbies

For other parent/guardian, if needed

Other Household Residents

Please provide a comprehensive list of other household residents: name, age, and relationship to student. For other parent/guardian household, if needed

Emergency Contact 1 *

First

Last

Other than parent/guardian.

Emergency Contact Phone Number 1 *

Emergency Contact 2 *

First

Last

Other than parent/guardian.

Emergency Contact Phone Number 2 *

Student's Current School *

Previous Schools Attended *

Please provide a comprehensive list of student's previous school(s) and grades attended

Student's Medical Concerns/Allergies *

Please provide a comprehensive list of student's medical conerns/allergies. If none type, N/A.

Student's Current Medication *

Please provide a comprehensive list of student's current medications. If none please type, N/A.

Describe Your Child *

Please include place in the family system, personality, likes and dislikes, etc...

Describe your child's strengths. *

Describe your child's challenges. *

List areas you feel your child needs remediation. *

Examples: math, reading, spelling, writing, social skills, life skills (money, tying shoes, telling time)

What accomodations do you and others find helpful for your child? *

Please attach most recent psycho-educational reports or IEPs, if applicable.

Click or drag files to this area to upload. You can upload up to 4 files.

What do you feel HCA has to offer your child? *

What are your hopes for your child? *

Is there anything else you wish to share about your child or your family?

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Hope Creek Academy

4723 Erwin Rd

Durham, NC 27705

(919) 932- 0360