Admissions Application: 2012-2013

Date: ______________________________________________________________
Students Name: ______________________________________________________
Students Preference of Name: ____________________________________________
Age: _____ Date of Birth: __________________ Place of Birth:_______________
Gender: ___________ Ethnic Origin (optional): _____________________________
Contact Information for Parents/Guardians
Name #1: __________________________________________________________
Address: ___________________________________________________________
__________________________________________________________________
Phone: _______________(home) _______________(cell) ________________(work)
Email Address: _______________________________________________________
Name #2: __________________________________________________________
Address: ___________________________________________________________
__________________________________________________________________
Phone: _______________(home) _______________(cell) ________________(work)
Email Address: _______________________________________________________

Educational History
Present School: ______________________________________________________

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com

Names and Dates of Past Schools Attended:

______________________________________________________________________________________
______________________________________________
What attributes are you looking for in a school for your child?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________
Please explain any concerns you have about your childs current educational placement and/or therapies.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________
What teaching methods have worked the best with your child? What methods have
not worked for your child?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Does your child have a current IEP? If yes, please attach.
__________________________________________________________________
Biomedical and Therapeutic Information
Does your child have any current health issues that you are addressing?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Describe your childs eating practices, including details about dietary restrictions,
food likes and dislikes, frequency, etc.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________
Please indicate whether your child is receiving/has received the following therapies or
support. Include details about setting/provider, dates, and dosage (if applicable):
ABA Therapy:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com

Occupational Therapy:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Physical Therapy:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Floortime Therapy:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Counseling/Psychology:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Prescribed Medications:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________
Other (Listening Therapy, Hippotherapy, etc.):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Please explain your childs diagnosis and whether this has changed/evolved throughout his or her lifetime:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Getting to Know Your Child

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com

Please describe your childs strengths.

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Please describe your childs challenges.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Please describe your childs favorite activities when s/he is alone, with family, and
with peers.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
How does your child interact with adults versus peers?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Describe a typical Saturday in your childs life.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Describe your childs response to routines and transitions, both at school (if applicable) and at home.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Please describe your childs individual hygiene habits, including eating, dressing, and
toileting.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Does your child ever exhibit self-injurious behavior or aggression? If so, please describe the circumstances.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Please explain if your child has any fears or anxiety.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com

Please describe your childs typical demeanor (attention seeking, calm, anxious,
mood fluctuations, etc.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
What is your childs primary method of communication (verbal, written, augmentative, PECS, sign?)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Please describe how your child uses language (for example, does s/he express wants
and needs? answer yes and no questions? engage in conversation?).
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Does your child follow directions?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
Is there anything else you would like us to know about your child?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com

Family Statement
Victory Academy relies on the strengths and talents of the Victory families and larger
community to support the school, its student programs, and model of
learning/growth.
If you were to join Victory Academy, in what ways would you be interested in
helping?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________

Please attach the following materials to the application:

Current IEP or Educational Report
Current Therapy Reports (OT, Speech, ABA, etc.)
Any other relevant documents
A photograph of your child
A $100 check to Victory Academy for the application fee
Please send all materials to Victory Academys secure PO BOX:
Victory Academy/PO BOX 428/Tualatin, OR/97062

Victory Academy, 27960 SW Canyon Creek Road, Wilsonville, OR, 97070

503-784-9717 | www.thevictoryacademy.com