ELSA PROGRAM APPLICATION Survey

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Complete All Sections of the Application

Please fill in all sections of this application. We request all sections be completed in order to assist us in determining the student’s admissibility to the program. The information provided will help us to better serve the admitted student. All information is confidential and will not be shared with any outside agencies unless written agreement is provided by those filling out the application.

PLEASE TYPE OR PRINT LEGIBLY

STUDENT INFORMATION

Last Name/First Name/Middle Initial
Current Address/Apt #
City/State/Zip
County/Providence/Township/Country
Home Phone (w/area code)
Cell Phone (w/area code)
E-mail Address
Date of Birth
Country of Birth
Social Security Number
Female/Male
Name(s) which may appear on student records (if different from above)
Permanent Address (if different from above)

2.	Is the student a US citizen? *
	Yes No

3.	If not a US citizen, does the student hold Permanent Resident (green card) Immigration Status?*
	Yes No

4.	If Yes, what is the student’s alien registration number?

5.	If not a US citizen or Permanent Resident, list country(ies) of citizenship:

6.	What is the student’s native/first language?

FAMILY INFORMATION

Mother: Last Name/First Name/Middle Initial
Home Phone (w/area code)
Address/Apt. #
City/State/Zip
Employer Name
Postion/Title
Employer Address
Work phone (w/area code)
Cell phone (w/area code)
E-mail Address
Father: Last Name/First Name/Middle Intial
Home Phone (w/area code)
Address/Apt. #
City/State/Zip
Employer Name
Postion/Title
Employer Address
Work phone (w/area code)
Cell phone (w/area code)
E-mail Address
Sibling Information:Name/Age/School
Name/Age/School
Name/Age/School
Name/Age/School

8.	Student lives with:
	Both parents Mother Father Guardian
	Other, please provide necessary information for contact

EMERGENCY CONTACT INFORMATION

IN CASE OF AN EMERGENCY, IF I CANNOT BE REACHED, PLEASE CONTACT:

Name:
Phone #:
OR: Name:
Phone #:

10.

STUDENT’S EDUCATION HISTORY:

Name of High School:
Years Attended:
Reason for Leaving:
When did/will student receive a high school diploma, certificate, or equivalent?
From which school listed above was/will this be granted?
If the student will not receive a diploma/certificate, or equivalent, please explain:
Please describe the student’s academic strengths and weaknesses:
Please describe the student’s learning style, including how the student approaches tasks and compensates for learning difficulties:
Has the student utilized any assistive technology? If yes, what?
Please list any significant medical conditions that may impact the student’s functioning on campus, including severe allergies:

11.	List any post secondary education experiences:

12.

STUDENT’S CURRENT EMPLOYMENT HISTORY

Complete the following if the student has had any prior work/employment/vocational experiences. NOTE: This is not a requirement for admission to this program.

Name of Business/Company:
Paid or Unpaid:
Job Responsibilities:
Reason for Leaving:
Amount of time at job:

13.

STUDENT’S PREVIOUS EMPLOYMENT HISTORY

Complete the following if the student has had any prior work/employment/vocational experiences. NOTE: This is not a requirement for admission to this program.

Name of Business/Company:
Paid or Unpaid:
Job Responsibilities:
Reason for Leaving:
Amount of time at job:

14.

STUDENT’S MEDICAL/DISABILITY HISTORY

NOTE: IF THE STUDENT MUST TAKE MEDICATIONS WHILE ON CAMPUS, HE/SHE MUST BE INDEPENDENT IN ADMINISTERING HIS/HER MEDICATIONS. ELMHURST COLLEGE DOES NOT HAVE THE PERSONNEL OR FACILITY TO ADMINISTER MEDICATIONS. THIS IS NOT INCLUDED IN ANY OF THE PROGRAM OR COLLEGE SERVICES.

Please list any significant medical conditions that may impact the student’s functioning on campus, including severe allergies:

Is the student currently taking any medications? If so, please list and indicate what the medications are being taken for:

Does the student currently receive private therapy services, such as physical therapy, occupational therapy, psychiatry, speech therapy, behavioral therapy etc.? If so, please describe:

15.	Additional Remarks: Please list/discuss any physical, intellectual, social, or emotional conditions that may need to be considered when planning a postsecondary experience for the student.

16.

FOR THE PROSPECTIVE ELSA STUDENT TO COMPLETE:

Short essay: To be completed by student with/without assistance from the parent/family/guardians/caregiver.

1. Why do you wish to be considered for the Elmhurst Life Skills Academy?

2. What is your vision for the future upon completion of the Academy?

3. Understanding that ELSA and families must work togather, what role will your family play in helping you achieve your vision?

17.

The information that I/we have provided in this application is honestly presented.

ELSA Applicant's Signature/Authorization:
Date:
Parent/Guardian's Signature/Authorization:
Date:

The ELSA Program evaluates all applications and administers all policies regarding admission, education, and school activities without regard to race, color, creed, national or ethics origin, marital status, age, gender, sexual orientation, disability or veteran status.