Application for Admission
802-251-7301
130 Austine Dr. #8
Brattleboro, VT 05301
www.theinspireschool.org
Admissions Policy
At INSPIRE for Autism, Inc. we seek to serve individuals who have a primary disability of
Autism Spectrum Disorders, which is a developmental disability significantly affecting verbal and
nonverbal communication and social interaction, generally evident before age three. Included in the
spectrum are: autism, pervasive developmental disorder not otherwise specified (PDD-NOS), Rett’s
Disorder, Asperger’s Disorder, and childhood disintegrative disorder as defined Vermont Agency of
Education Special Education Guide. We serve students age 7-21 whose chronological age would
place them in elementary, middle school, or high school.
We offer educational and vocational training which will maximize the potential for adolescents and
young adults with autism to lead satisfying, self-sustaining lives in connection with their
communities.
Enrollment for:
Full-Time Placement _______ Part-Time Placement _______
A complete application includes:
____ Application for Admission
____ Parent Questionnaire
____ Copy of current IEP or other plan (if applicable) –including most recent assessments
____ Current triennial evaluation and/or any other current evaluations such as occupational/physical
Therapy, speech/language, educational, psychological, etc.
____ Copy of most recent progress report or Report Card
____ Birth Certificate or Guardianship documents
____ Custody Document when the child is not living with both natural parents or when there are
legal directives regarding the custody of the child
_____ Immunization Record
_____ Health Insurance Card (both sides)
_____ Medical examination form completed by the doctor (within the last 12 months)
_____ Information regarding social services the child has received to date
_____ Request for Records
Admissions Process
INSPIRE for Autism, Inc. has a limited number of openings each academic year. We will consider
and approve applications as they are completed and will produce a waiting list for future enrollment.
All applicants to INSPIRE School for Autism are considered on the basis of individual needs and the
ability of INSPIE to provide an appropriate educational program to meet those needs. It is the
policy of INSPIRE to consider all applicants without regard to their actual or perceived race, creed,
color, national origin, marital status, sex, sexual orientation, gender identity, or disability.
We encourage parents/guardians to set up an IEP meeting with their child’s current placement to
begin the process for enrollment to INSPIRE. Placement is an IEP team decision and INSPIRE will
not accept students without the approval of the local public school agency (LEA) except under
extraordinary circumstances such as 1) parents/guardians assume full responsibility for tuitin costs
or 2) student placement is so designated via court order. INSPIRE staff will not be part of the
decision-making process, however, we are available to present information about INSPIRE to your
child’s IEP team and will provide support as necessary. Should you have any questions, please do
not hesitate to contact Kristin Smith Office Manager: 802-251-7301 or email:
ksmith@theinspireschool.org.
Application for Admission
Applicant Information:
Name of applicant
_____________________________________________________________
First
Middle
Last
Nickname
Male or Female: ____________________
Anticipated Entrance Date: _____________
Date Of Birth: ____________________
Place of Birth: ______________________
Citizenship: ____________________
Parent or Guardian:
Parent or Guardian:
Name: _____________________________________
Name: ______________________________________
Address: _____________________________________
Address: ______________________________________
_____________________________________
______________________________________
Telephone: _____________________________________
Telephone: ______________________________________
Fax: _____________________________________
Fax: ______________________________________
Email: _____________________________________
Email: ______________________________________
Occupation: _____________________________________
Occupation: ______________________________________
Work
Work
Address: _____________________________________
Address: ______________________________________
_____________________________________
______________________________________
Telephone: _____________________________________
Telephone: ______________________________________
Fax: _____________________________________
Fax: ______________________________________
Email: _____________________________________
Email: ______________________________________
Parental Status
Parental Status
Married: _______
Separated: _______
Married: ________
Separated: ________
Divorced: _______
Widowed: _______
Divorced: ________
Widowed: ________
Single Parent: _______
Other: _______
Single Parent: _______
Other: ________
Name of Custodial Parent (if necessary):
______________________________________________________________________________
(A copy of the custody agreement must accompany the enrollment materials.)
Person to whom communications should be sent:
Mother ________
Father ________
Both ________ Guardian __________
Names and ages of brothers and sisters and schools they attend:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________
Emergency Contact Person (in case parent or guardian cannot be reached):
Name: _______________________________________________________________________
Address: ______________________________________________________________________
Telephone: ____________________________________________________________________
Relation to applicant: ____________________________________________________________
Current/Sending School Information:
Present school: _________________________________________________________________
Address: ______________________________________________________________________
Telephone: ____________________________________________________________________
Case Manager: _________________________________________________________________
Principal: _____________________________________________________________________
Grades or years attended: _________________________________________________________
Description of Current Placement/Level of Support:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________
Billing Information:
Name: ______________________________
Address: ____________________________
____________________________
Telephone: __________________________
Fax: ________________________________
E-mail: _____________________________
In order to process this applicant’s Admission Application, the undersigned agrees that all information received
by the Admission Office, from any source, shall be completely confidential and will not be divulged to anyone,
including the candidate and his/her family, unless such disclosure is deemed by the head of school or the
director of admission to be necessary and appropriate.
________________________________________
Parent or Guardian Signature
______________________________
Date
Parent Questionnaire
Name of applicant ___________________________________________________________________
Name of Parent(s): ______________________________________________________________
Tell us about your son/daughter’s strengths:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________
Tell us about your son/daughter’s challenges:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________
Tell us about your son/daughter’s interests:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________
Brief History (other treatments sought, successful programs, diagnostic report):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________