Hampshire Country School Application

Student Information

First Name*

Last Name*

Date of Birth*

Applicant's Address*

Use Google Smart Search for Address

Address 1:

City:

Country:

State/Province:

Postal Code:

What program are you applying to?*Full School Year (September to June)Summer Camp (July)

When are you interested in having your child enroll?*

What is the applicant's relationship with "Other Person"

What is applicant's primary language*EnglishOther Language

What Language if "Other"

Student's Ethnicity*

Is student adopted? *

Age of Adoption*

Where was the applicant born?*

How many siblings does the applicant have?*

Who should recieve correspondence regarding the applicant*

Who is financially responsible for applicant?*

Has any relative ever attended Hampshire Country School?*

If yes, give name, relationship with applicant, and dates*

Parent / Guardian 1 Information

Parent / Guardian 1 First Name *

Parent Guardian 1 Last Name*

Is Parent / Guardian 1 address different from child's mailing address?*

If YES, what is Parent / Guardian 1 address?*

Use Google Smart Search for Address

Address 1:

City:

Country:

State/Province:

Postal Code:

Parent/Guardian 1 e-mail*

Parent / Guardian 1 phone* - -

Parent/Guardian 1 birthday*

Parent/Guardian 1 occupation*

Parent/Guardian employer*

Briefly describe the relationship between Parent/Guardian 1 and applicant*

Parent/Guardian 2 Information

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Is Parent / Guardian 2 address different from child's mailing address?

If YES, what is Parent / Guardian 2 address?

Use Google Smart Search for Address

Address 1:

City:

Country:

State/Province:

Postal Code:

Parent/Guardian 2 email address

Parent/Guardian 2 Phone - -

Parent/Guardian 2 birthday

Parent/Guardian 2 occupation

Parent/Guardian 2 employer

Briefly describe the relationship between Parent/Guardian 2 applicant

Referral Information

How did you first hear of Hampshire Country School?*

What is the name(s) of referral source*

Referral phone - -

Referral email

Educational Information

What grade is applicant entering in September?*

Is applicant currently attending school?*

What is the name of their current school?*

Why are you interested in having your student change schools at this time?*

List all previous schools and grades applicant has attended*

What are your student's strongest subjects?*

What are your student's most challenging subjects?*

Has the applicant been assessed for learning disabilities?*

If yes, please describe*

Has the applicant ever received intervention or remediation for learning disabilities?*

If yes, please describe*

Has applicant ever been asked to leave a school?*

If yes, please give dates and reasons*

What are your student's extracurricular interests, what do they do for fun?*

Why do you think Hampshire Country School might be a good match for your child?*

What is your greatest concern about your child's time at a boarding school?*

Psychological History

Please describe any major events the applicant has struggled with (divorce, moving, birth of siblings, loss, abuse, illness etc.) please include date*

Stress: describe the way(s) in which the applicant expresses stress*

Has the applicant had any physical confrontations in the home or with others?*

If yes, describe with whom and the circumstances*

Has applicant intentionally hurt himself? *

If yes, please describe (include date/reason)*

Has applicant ever run away?*

If yes, please describe (include date, how long, where, contacted you? etc.)*

Has the applicant ever expressed thoughts of suicide or intentions to hurt themselves?*

If yes please describe (specify date and reason)

Does the applicant make sexualized statements or display sexualized behaviors?*

If yes, please describe*

Does the applicant exibit signs of anxiety, depression, mood swings, etc.*

If yes, please describe*

Does applicant display tics or use repetitive actions for stimming?*

If yes, please describe*

Has the applicant been involved with lying, theft, or vandalism? *

If yes, please descibe activity including dates*

Does the applicant have unusual behaviors (tics, chewing, pulling hair etc.) *

If yes, please describe*

"Does applicant display any addictive patterns ?"*

What is the nature of these patterns?*

What behaviors and idiosyncrasies contribute to your child's challenges at HOME (bedtime routines, food preferences or restictions etc)?*

What behaviors or idiosyncrsies contribute to your child's challenges at SCHOOL?*

Medical History

Is there any medical or psychological history that may interfere with your child's ability to participate fully in the school's programs?*

Please list any surgeries, serious illness and/or hospitalizations. Please include dates*

Please list any prescriptions the applicant is currently taking, dosage, frequency and the reason for each*

Are there any known side effects of the medications?*

If yes, please descibe*

What does applicant do for exercise? *

Describe any pertinant medical/physical history that might inhibit physical activity*

Does the applicant have any dietary restrictions, allergies, or preferences??*

If yes, please describe*

Decribe any over-sensitivity or under-sensitivity to touch, light, sounds, temperature or coordination?*

Parent and Student Statements

What are YOUR expectations for your child's first year at Hampshire Country School?*

What are YOUR CHILD"S expectations for his first year at Hampshire Country School?*

Required Attachments

Photo of Applicant *

(gif, jpeg, jpg, pdf, png)

Assessment Report *

(doc, docx, pdf)

IEP or 504 plan *

(doc, docx, pdf)

School reports *

(doc, docx, pdf)

Special services or other reports*

(doc, docx, pdf)

How to Apply

APPLICATION FOR ADMISSION

Student Information

Parent / Guardian 1 Information

Parent/Guardian 2 Information

Referral Information

Educational Information

Psychological History

Medical History

Parent and Student Statements

Required Attachments