Sign Up · The Community Learning Center

Fill out the application below and click Generate Application PDF. Your completed form will download to your device, ready to email to us at qualityeducation3@gmail.com or bring in. Fields marked * are required.

1 General Information

About the student applying.

First Name *

Middle Name

Last Name *

Date of Birth *

Age

Sex

Grade Applying For

Place of Birth

Nationality

Religion

Last School Attended

Home Address *

Reason for Assessment

Email Address

Telephone # *

Person Responsible for Fees

2 Family Demographics

Parents/guardians and siblings.

Father

Name

Employment

Telephone #

Mother

Name

Employment

Telephone #

Siblings (names & ages)

3 School History

Schools the student has attended, and any areas of concern.

Previous Schools (names & addresses)

Academic / behavioral areas of concern

Concern 1

Concern 2

Concern 3

Has the student ever received disciplinary action (suspension, expulsion)? If yes, explain.

Has the student ever received any type of therapy? If yes, explain.

4 Current Health & Mental Status

Please answer as best you can.

How is your child's health? Frequently ill or relatively healthy?

Does your child complain of aches and pains often?

Is your child taking any medications?

Does your child complain about going to school?

Does your child bring work home to show, or hide it?

What does your child like to do best at home?

5 Emergency Contact & Insurance

Emergency Contact Name

Relationship

Home Phone

Work Phone

Mobile / Cell

Is the child covered by medical insurance?

Name of Insurance Company

6 Certification

Parent / Guardian Full Name *

I certify that all information on this form is true and correct.

Email Us Instead

Your information is used only to generate this application on your own device. Nothing is sent or stored anywhere until you email the downloaded PDF to the school.

📞 (242) 362-1115 ✉️ qualityeducation3@gmail.com