THE NEXUS SCHOOL
2801 Woodland Rd. Roslyn, PA 19001
Telephone: 215-657-2434
E-mail: vickiwest10@verizon.net
Important -- Applications will be processed in order of receipt.
The Nexus School admits students of any race, color, disability, sexual orientation, national and ethnic
origin to all rights, privileges, programs, and activities generally accorded or made available to students
at the School. It does not discriminate on the basis of race, color, gender, disability, sexual orientation or
national and ethnic origin in administration of its educational policies, admission policies, scholarship
and loan programs, and other School-administered programs.
Application for Admission
Date
______ Application for School Year:
Applicant’s Legal Name - Last
_______________________
First
Middle
(If student has a double or hyphenated last name, please indicate preferred order.)
Preferred Name
Date of Birth
Gender: Female  Male 
Place of Birth
Current Grade:
Family Information
Parent/Guardian *
Parent/Guardian *
Name
Name
Street Address
Street Address
City, State, Zip Code
City, State, Zip Code
Home Telephone
Home Telephone
E mail
E mail
Employer/Position
Employer/Position
Work Telephone
Work Telephone
* All school mailings will be sent to both parents/guardians unless we are notified in writing otherwise. Please
attach information regarding any other parents/guardians of the Applicant.
Application page 2
• Please list names, birth dates and schools of other children in the Applicant's family/household:
Please list names and ages of other individuals who reside in the household with the Applicant.
Current School Information
Current School
Dates of Attendance
School Address Street, City, State, Zip Code
Telephone
Current Teacher(s)
Principal
School(s) Previously Attended (Names & Dates)
Additional Family Information
What is your child’s primary language?
What languages are spoken in your home?
If parents/guardians are not married, or are separated or divorced, with whom does the child live?
Who is financially responsible for the child’s education?
If other than parents/guardians, please explain.
Student Description - Mandatory
1. Please discuss on separate pages your goals for your child’s education and expectations you have for
his/her school.
Discuss or describe:
 Why your child’s current educational program is, or is not, meeting your child’s needs;
 How well your child relates to other family members and classmates;
2. Does your child have any compulsive or obsessive behaviors? Please describe.
3. Does your child have any aggressive/tantrum behaviors? Please describe.
Application page 3
4. Describe your child’s ability to attend to instruction/ Do attending issues change based on
activity/environment/ and teacher-child ratio
5. Does your child have any anxiety/rigidity issues? Please describe.
6. Does your child have particular transition issues? Please describe.
7. Would your child attempt to wander away from school premises?
8. Is your child toilet trained? Partially trained? Please describe.
9. Please list on a separate sheet any allergies - environmental and food - that the Applicant has and
include type of reaction he/she experiences.
10. Are there any medical, emotional/behavioral, physical or other issues that might interfere with his/her
optimal school adjustment that you have not already described?
Also, please provide copies of all reports that relate to your child from psychologists, psychiatrists,
neurologists, behavioral specialists, occupational therapists, and speech and language pathologists, and
IEPs produced in the past 24 months. You may also provide other pertinent information that will help us
accurately evaluate your child. Please list below each report writer’s name and phone number, in case
TNS needs clarification or additional information relating to any submitted report.
Teacher References
This reference is due after the child has been determined to be a “fit” for TNS and before the formal
acceptance agreement with your school district.
Please note the name(s) and address(es) of teacher(s) completing the Reference Form:
Name(s)
Name(s) and Address(es) of School(s)________________________________________________________
Telephone Number(s)____________________________________________________________________
Application page 4
Behavioral Consultant Reference
This form is due prior to the child’s visitation at TNS.
Please note the name and address of behavioral consultant completing the Reference Form:
Name
Address
Telephone Number(s)
To The Parent/Guardian:
Thank you for your interest in The Nexus School. Your signature below grants TNS permission to secure further
information pertaining to the child’s formal acceptance at TNS.
I/We understand that all Admission information is confidential and will be held securely for 2 years and then
shredded if my child is not admitted.
I/We understand that all information regarding a candidate's application for admission to The Nexus School will
be treated with complete confidentiality. Only authorized TNS personnel have access to this information, and
then only to the extent that the information is relevant to The Nexus School admission and placement
decisions. Information received within the scope of this policy is not disclosed to the applicant or to the
applicant's family.
I/We hereby state that the information contained herein is true and complete. I/We have not knowingly or
intentionally omitted any pertinent or requested information regarding my/our child's academic, medical, or
behavioral history.
Signature of Parent/Guardian
Date
Signature of Parent/Guardian
Date
Application page 5
THE NEXUS SCHOOL
2801 Woodland Road • Roslyn, PA 19001
Telephone: 215-657-2434
Email: vickiwest10@verizon.net
Current School Report Request
To the Parent/Guardian:
Please complete this section, sign below, and give this to your child’s current school administrator.
Applicant Name
Applying for Grade
Current School
Current Grade
I give permission for my child’s school records to be sent to The Nexus School.
I understand that all references pertaining to this application are confidential.
Signature of Parent/Guardian
Date
Dear Colleague:
The child indicated above has applied for admission to The Nexus School. We are requesting a copy of the student’s report
cards, transcripts or school progress reports. We would also greatly appreciate any information you might share about
her/his academic, social, and emotional development. We do not require standardized tests, but if you have test results
available they would be helpful to us, as would any other material relevant to the child’s readiness for the grade to which
she/he is applying. Please see the attached TNS Statement of Confidentiality. You may use the reverse side of this sheet
for your remarks or attach a separate page. We would particularly appreciate comments on the following:
For All Applicants
 How long have you known this student?
 Has this student been suspended or expelled for any reason during the last three years?  Yes  No If
yes, please give full details, including date, nature of incident, and nature of discipline. Suspension or
expulsion will not necessarily bar admission.
For Pre-Kindergarten through Grade 2
• Class size and age range of group
• Social and emotional adjustment
• Curiosity
• Attention span
For Grades 3-8
• Length of time enrolled in present school
• Academic progress
Basic skills, strengths and weaknesses
Attitude toward learning
Ability to concentrate and follow through
• Number of hours and days per week child is in class
• Motor Coordination (gross and fine)
• General health
• Class size
• Social and emotional adjustment
Relationship to peers
Self-confidence
• Special interests
This completed form with any attached narrative, along with a copy of the child’s report cards, and transcripts or school progress
reports, should be returned to the address selected by the parents at the top of this form as soon as possible. Thank you
for your assistance.
School Administrator’s Signature (please print name above or beside signature)
School Address
Date
Telephone Number
Application page 6
The above form will be sent after a formal acceptance has been reached between TNS and the SD.

The Nexus School Statement of Confidentiality

All information regarding a candidate's application for admission to The Nexus School will be treated
with complete confidentiality. Only authorized The Nexus School personnel have access to this
information, and then only to the extent that the information is relevant to The Nexus School admission
and placement decisions. Information received within the scope of this policy is not disclosed to the
applicant or to the applicant's family.