Harbor Leadership
Academy
17317 FM Road 1431
Leander, TX 78641
512.219.5673
512.219-5679 Fax
www.harboracademy.com
admin@harboracademy.org
Application for Admission
Student Name ______________________
Current Grade ______________________
Applying for Grade __________________
Date of Application __________________
Photo
Here
For Office Use Only
Application
for Admission
page 1
Received:___________
Harbor Leadership
Academy
Admission Procedure
Thank you for your interest in Harbor Leadership Academy. If you have any questions about the application
process, please feel free to contact Tifannie Snider, Harbor Registrar at 512.219.5673. All Admission forms can be
found on our website, www.HarborAcademy.org.
STEP 1 – CONSULTAION
If you decide to pursue enrollment in Harbor Academy for your child, please call us at 512.219.5673 to
arrange a time to meet with a member of the admissions committee, tour the school, and discuss your
child’s current and past school records and any formal testing which has been completed (a copy of the
most recent evaluation should be sent in with your application). These tours are made by appointment
and are scheduled for Tuesdays and Thursdays. Please bring completed Parent Intake form to this
appointment, which can be found on our website, www.HarborAcademy.org.
STEP 2 – APPLICATION
The full admission process includes a student on-campus visit. This will be arranged after the initial
consultation step 1, as well as the following:




Completed application
Copy, (or medical release signed for) of all testing assessments (including speech-language,
neurology, educational and psychological evaluations, OT, PT)
Signed release to Harbor Academy for records from the applicant’s schools
Signed Parent/Student Responsibilities Agreement and Handbook Agreement
Upon review, Harbor staff will contact you to schedule your student’s on-campus visit.
STEP 3 – ADMISSIONS
Following the visit, the admissions committee meets to discuss each applicant. The admissions
committee will make one of three recommendations for a student: recommend conditions of placement
in Harbor Academy, request additional information, or recommend alternative placement in a program
other than Harbor for the student. Parents are then notified by the admissions committee. Individualized
diagnostic testing will be set up through our Testing Center (additional fee). The three minimum criteria
for admission are:
 Applicant must have a documented learning disability in order to receive special services
 Applicant must have the potential to be an average-to-above-average IQ
 Applicant’s enrollment will not negatively affect the school community and/or the learning
experiences of other students, and family must be open to counsel
Application for Admission
page 2
Harbor Leadership
Academy
Application for Admission
This application is for:
___ Immediate Placement
___ Placement at the start of the next school year
APPLICANT INFORMATION
______________________________________________________________________________
FIRST NAME
MIDDLE NAME
LAST NAME
PREFERRED NAME
________________________________________________________________________________________________________
HOME ADDRESS
CITY
STATE
ZIP CODE
_________________________________________________________________________
DATE OF BIRTH
CURRENT AGE
SOCIAL SECURITY #
______ MALE ______ FEMALE
PARENTS OR GUARDIANS WITH WHOM THE APPLICANT LIVES
PARENT/GUARDIAN #1 _____________________________________________________________________________________
FIRST NAME
LAST NAME
RELATIONSHIP TO APPLICANT
________________________________________________________________________________________________________
HOME PHONE
CELL PHONE
EMAIL ADDRESS
________________________________________________________________________________________________________
EMPLOYER
POSITION
WORK PHONE
PARENT/GUARDIAN #2 _____________________________________________________________________________________
FIRST NAME
LAST NAME
RELATIONSHIP TO APPLICANT
________________________________________________________________________________________________________
HOME PHONE
CELL PHONE
EMAIL ADDRESS
________________________________________________________________________________________________________
EMPLOYER
POSITION
WORK PHONE
PLEASE CHECK IF APPLICABLE:
____ Parents separated
____ Parents divorced
____ Father deceased
____ Mother deceased
____ Father remarried
____ Mother remarried
If parents are separated or divorced, who has legal custody (Documentation required) _________________________________
Who has physical custody and what are the arrangements (Documentation required) __________________________________
Application for Admission
page 3
PARENTS OR GUARDIANS WITH WHOM THE APPLICANT DOES NOT LIVE (If Applicable)
PARENT/GUARDIAN #1 _____________________________________________________________________________________
FIRST NAME
LAST NAME
RELATIONSHIP TO APPLICANT
________________________________________________________________________________________________________
HOME PHONE
CELL PHONE
EMAIL ADDRESS
________________________________________________________________________________________________________
EMPLOYER
POSITION
WORK PHONE
PARENT/GUARDIAN #2 _____________________________________________________________________________________
FIRST NAME
LAST NAME
RELATIONSHIP TO APPLICANT
________________________________________________________________________________________________________
HOME PHONE
CELL PHONE
EMAIL ADDRESS
________________________________________________________________________________________________________
EMPLOYER
POSITION
WORK PHONE
FAMILY BACKGROUND
Are there any languages other than English used in the home? If so, please specify ____________________________________
Are there any siblings in the home? Please list name, age, and school:
Brothers
___________________________________________
Sisters
________________________________________________
___________________________________________
________________________________________________
Others residing in the home _________________________________________________________________________________
Do/Did relatives of the applicant have significant problems in school, or with applicant? If so, please explain.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
LEARNING CHALLENGES
Has student ever been suggested to have academic, emotional, behavioral, neurological, or psychological issues?____________
Specific diagnosis or suspicions of applicant’s issues of learning difference, mental, emotional or physical (etc) and symptoms.
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
Has applicant ever been in a treatment program residential, or out-patient? __________ If yes, explain____________________
________________________________________________________________________________________________________
Application for Admission
page 4
LEARNING CHALLENGES cont.
Does the applicant take prescribed medication or natural supplements? If yes, please specify the name of the medication,
reason and times administered; use additional paper if needed
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Has applicant been prescribed medication in past and not continued? _________If yes, reasoning: ________________________
________________________________________________________________________________________________________
All professionals past and presently working with applicant: (Doctors, speech/language pathologist, psychologists, counselors,
etc.) Please be thorough, and use additional pages if necessary.
________________________________________________________________________________________________________
NAME
RELATIONSHIP TO APPLICANT
CITY/STATE
PHONE
________________________________________________________________________________________________________
NAME
RELATIONSHIP TO APPLICANT
CITY/STATE
PHONE
________________________________________________________________________________________________________
NAME
RELATIONSHIP TO APPLICANT
CITY/STATE
PHONE
Discuss applicant’s history of experimentation with tobacco, drugs or alcohol. Please explain details______________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Does the applicant have any condition which might interfere with their full participation in all aspects of Harbor Leadership
Academy (including but not limited to recess, classwork, field trips, physical activities, etc.)? If so, please explain.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
ACADEMIC HISTORY
Schools attended:
School
City/State
Grade(s)
Reason for Leaving
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Application for Admission
page 5
Discuss any disciplinary actions, detentions, suspensions, expulsions, ISS, or alternative education experiences. Give specific
details.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Has the applicant repeated or skipped a grade? If so, give details: __________________________________________________
________________________________________________________________________________________________________
Please describe any tutoring the applicant has had, including dates. _________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
What problems and when did you first become aware of a problem in school? ________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Please state your expectations of Harbor Academy in its work with your student ______________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
LEARNING PROFILE
Please list the areas of the applicant’s talent or interest. __________________________________________________________
________________________________________________________________________________________________________
The applicant is happiest when ______________________________________________________________________________
_______________________________________________________________________________________________________
The applicant is resistant or unhappy when ____________________________________________________________________
________________________________________________________________________________________________________
Please describe the applicant’s strengths and challenges in the following areas:
Phonics _________________________________________________________________________________________________
Reading comprehension ____________________________________________________________________________________
Application for Admission
page 6
LEARNING PROFILE cont.
Spelling _________________________________________________________________________________________________
Handwriting _____________________________________________________________________________________________
Written expression (ability to express thoughts in writing) ________________________________________________________
Memory for math facts (addition, multiplication, etc.) ____________________________________________________________
________________________________________________________________________________________________________
Understanding of math concepts (such as knowing how to add or multiply) ___________________________________________
________________________________________________________________________________________________________
Solving word problems _____________________________________________________________________________________
Science _________________________________________________________________________________________________
Social Studies/History ______________________________________________________________________________________
Ability to follow directions; written, verbal, implied _____________________________________________________________
Ability to self-advocate, and express needs _____________________________________________________________________
________________________________________________________________________________________________________
LIST ANY OTHER CONCERNS OR ISSUES NOT STATED ABOVE THAT WOULD HELP HARBOR TO UNDERSTAND YOUR CHILD:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
The involvement and support of each student’s family in an integral part of Harbor Leadership Academy and is critical to our
success. Harbor Academy is committed to working as a team consisting of student, teachers and parents to provide every
opportunity for success. Parents will also be asked to contribute time and talent at various times during the school year. Please
make sure you understand the commitment we ask of parents prior to submitting this application.
_____________________________________________
PARENT SIGNATURE
DATE
_____________________________________________
PARENT SIGNATURE
DATE
Harbor Leadership Academy admits qualified students and does not discriminate on the basis of race, color, religion, sex, or national origin, in
the administration of its education program, admissions, financial aid, athletics or other school policies. All students are afforded the rights,
privileges, programs and activities generally accorded or make available to Harbor Leadership Academy students.
Application for Admission
page 7
Harbor Leadership
Academy
Student Records Release Authorization
I hereby grant Harbor Leadership Academy permission to request records pertaining to my
child, _________________________________________ from his/her previous school or
academic and medical professionals who have worked or working with him/her.
Records pertaining to the following should be included:






Academic
Attendance
Behavior
504
Special Education
Medical Diagnosis and Treatments
Name and address of precious school or other professional:
______________________________________________________________________________
NAME
PHONE
FAX
_____________________________________________________________________________________
ADDRESS
CITY/STATE
ZIP
_____________________________________________________________________________________
PARENT SIGNATURE
NAME (PLEASE PRINT)
_________________________________________
DATE
Please mail or fax this form along with all student records to:
Harbor Leadership Academy
Phone: 512.219.5673
17317 FM RD 1431
Fax: 512.219.5679
Leander, TX 78641
Admin@harboracademy.org
Application for Admission
page 8
Harbor Leadership
Academy
Recommendation Forms
Parents: Please provide your child’s current/past schools with this form and three copies of the teacher
recommendation forms.
I hereby grant Harbor Leadership Academy permission to request information and records pertaining to my child,
______________________________________ from his/her previous school or other professionals who have
worked or are working with him/her.
I further request that the school principal and two other teachers from the current or previous school year submit
the following recommendation to Harbor Leadership Academy. I waive my right of access to this recommendation
and understand that it will not become part of his/her permanent record. (Parents, please forward this from to
the appropriate persons).
__________________________________________
___________________________________________
PARENT/GUARDIAN NAME (PLEASE PRINT)
PARENT/GUARDIAN SIGNATURE
__________________________________
DATE
Teachers please fill out the recommendation form and mail or fax it to:
Harbor Leadership Academy
17317 FM RD 1431
Leander, TX 78641
Phone: 512.219.5673
Fax:
512.219.5679
Admin@harboracademy.org
Name and address of School or Institution: __________________________________________________________
_____________________________________________________________________________________________
__________________________________________
___________________________________________
PHONE NUMBER
FAX NUMBER
__________________________________________
NAME OF EVALUATOR (PLEASE PRINT)
_____________________________________________________________________________________________
RELATIONSHIP TO STUDENT
Application for Admission
page 9
Teacher Recommendation Form
Name of person completing form:__________________________________________________________________
How long and in what capacity have you know the applicant? ___________________________________________
_____________________________________________________________________________________________
Has the child named on the reverse of this form had discipline problems (either major or minor)?
Yes
No
(Please circle appropriate answer). If yes, Please explain below:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
To your knowledge, has this student had any violations of the law?
Has this student been known to use drugs or alcohol?
Has this student been suspended?
Is this student allowed to return to your school?
Has this student ever left class or the school without permission?
YES
YES
YES
YES
YES
Please rate the student in the following areas – Circle the correct answer
Seldom
Most Times
This student is cooperative.
1
2
3
This student is respectful.
1
2
3
This student is in compliance with school rules.
1
2
3
This student is in good standing (regarding discipline).
1
2
3
This student has good peer relationships
1
2
3
The parents are supportive of the school and its policies
1
2
3
The student gets along with peers
1
2
3
The student has emotional outbursts
1
2
3
Is there any additional information you would like to share with the admissions committee?
NO
NO
NO
NO
NO
4
4
4
4
4
4
4
4
Always
5
5
5
5
5
5
5
5
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Please mark the appropriate space:
_______ Strongly recommend
_______ Recommend
_______ Recommend with reservations
_______ Do NOT Recommend
________________________________________________
SIGNATURE OF EVALUATOR
___________________________________
DATE
Application for Admission
page 10