Student/Family Info Parents/Guardians Info Student Questionnaire Recommendations Payment Student First Name Student Last Name Parent/Guardian Email ----------------Please answer the following questions to the best of your ability. Be sure to answer truthfully and in detail.---------------------- How did you hear about Bridgeport International Academy? Why are you interested in sending your child to this Academy? What academic, social, artistic, and/ or spiritual goals do you have for your child as s/he moves on to high school? Are there any extenuating circumstances that we should know about that might help us understand or interpret your child's past academic record? Has your child ever been expelled from a previous school. If so, please explain the circumstances. Has your child ever been diagnosed with a learning disability? Yes No Has your child ever been evaluated or diagnosed with ADD (Attention Deficit Disorder) or ADHD (Attention Deficit Hyperactivity Disorder)? Yes No Has your child ever been evaluated or tested for or participated in a gifted program? Yes No Has your child ever undergone psychiatric evaluation or been under the care of a psychologist, psychiatrist, or other therapist during the past five years for any reason? Yes No Has your child ever experienced any difficult challenges or personal setbacks in recent years? Yes No Has your child ever used alcohol, cigarettes, or illegal drugs? Yes No Has your child ever been suspended or dismissed from school? Yes No At present, does your child have restrictions of any kind on his/her participation in school sports or other activities? Yes No Additional explanation of the above: Also, please include any other information about your child you feel we may have missed. For example, you may want to describe interesting talents, hobbies, or activities. Submit
