Omega Middle School Application Step 1 of 5 20% Applying for grade:*6th Grade7th Grade8th GradeBeginning Date (Month and Year)*Applicant's Name* First Last Middle Name*Preferred Name*Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleRace / Ethnicity*African-AmericanAsianHispanicWhiteOmega welcomes families of all races, nationalities, creeds, religions, sexual orientations, and social and economic backgrounds.Where did you learn about Omega? Please check al l that apply.* RCS Website Omega Website Google Ads Blog Local Reputation Driving/Walking by Facebook Magazine Friend/Acquaintance Other Please be specific: Student lives with*Mother & FatherMotherFatherGuardianCheck any that apply Parents Married Parents Divorced Parents Separated Father Deceased Mother Deceased Who will accept financial responsibility for school tuition & fees?*MotherFatherBothIs your child's enrollment dependent upon receiving tuition assistance?*YesNoParent / Guardian Information 1Parent / Guardian Information 1* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Mobile PhoneWork PhoneOther PhoneOccupation*EmployerParent / Guardian Information 2Parent / Guardian Information 2* First Last Is the Parent / Guardian address the same?*YesNoAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Mobile PhoneWork PhoneOther PhoneOccupation*EmployerParent / Guardian Information 3 (if applicable)Parent / Guardian Name 3 First Last RelationshipAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Mobile PhoneWork PhoneOther phoneOccupationEmployerMaternal GrandparentsGrandparents are contacted a few times a year for school purposes - newsletters, invitations, and annual campaign.NamesAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhonePaternal GrandparentsGrandparents are contacted a few times a year for school purposes - newsletters, invitations, and annual campaign.NamesAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone Educational HistoryCurrent RCS and / or OMS Family or Alumni Names (if applicable)Applicant's Current School*Primary Teacher(s)*School's Phone Number*Please list applicant's recent school experience:*Name of SchoolCity, StateGrades enrolledAcademic year(s) Please describe your child’s previous school experience, both positive and not-so-positive.*Please list name, gender, grade and current school for all other children in your family:NameName of SchoolGradeGender Does your child speak Spanish?*none at alla little bitfluent in SpanishIn which grade(s) has your child studied Spanish (if any)?Please comment on your child’s strengths, challenges, special needs, and special interests.* Please respond to the following by indicating whether your child is:Interaction with peers*advancedon targetslightly delayeddelayedInteraction with adults*advancedon targetslightly delayeddelayedAbility to focus and complete tasks*advancedon targetslightly delayeddelayedAbility to follow spoken directions*advancedon targetslightly delayeddelayedCoordination (large motor skills)*advancedon targetslightly delayeddelayedHandwriting*advancedon targetslightly delayeddelayedAbility to understand written directions*advancedon targetslightly delayeddelayedMathematical computations and problem solving*advancedon targetslightly delayeddelayedResponsibility*advancedon targetslightly delayeddelayedHonesty/Integrity*advancedon targetslightly delayeddelayedCooperation*advancedon targetslightly delayeddelayed Health & Behavioral InformationDoes the applicant have any physical impairment or allergies which would, in any way, affect participation in the full range of school activities?*YesNoDoes the applicant have any recent serious physical or emotional illness, which requires, or has required, the care of a physician?*YesNoIf the answer to either of the two previous questions is “yes,” please give detail*Does your child have discipline issues either with you and/or with others? If yes, please explain.How likely is your child to distract or be easily distracted by others? Please explain circumstances.Has your child been recommended for evaluation, been evaluated or identified as having learning differences, developmental or motor delays, visual, auditory or other sensory processing difficulties, behavior or emotional disorders (ADD, ADHD, Autism (ASD) , OCD, Asperger’s, etc.)? Or, do you suspect that your child may have any of the above delays or differences? If yes, please explain.Has medication been recommended or been taken by your child to address any of the above diagnoses? If yes, please specify the name of medicine and dosage.If your child has been evaluated by one or more specialists, please list their name(s) and phone number(s).NameTitlePhone number Has your child ever been suspended or dismissed for academic, honor, disciplinary or other reasons? If yes, please explain.*Failure to disclose information could result in your being required to withdraw your child and forfeit tuition. After evaluation, a decision will be made and you will be notified. If the applicant is accepted, you will need to sign an enrollment contract and send in a tuition deposit. An enrollment contract is for one year only, or in the case of a transferring student, from the time of transfer to the end of that school year. Granting of subsequent contracts for future years is subject to annual decision on the part of the school. If, after being accepted, a student is found to have special needs that that no one was previously aware and/or to an extent that Omega Middle School cannot provide for, the school may terminate contract. In this case, the parent(s) or guardian(s) would be released from their tuition contract. If special needs from a student support staff are deemed necessary, there will be additional fees for providing extra assistance and accommodations in the classroom.* I certify that all information that I have provided on this application is accurate and authorize the release of all information from evaluation specialists and previous teachers to the teachers and administrators at Omega Middle School. Your Name* First Last Your Email* We'll use this email address for future communications regarding your application.Application Fee* Price: $75.00 This payment is a non-refundable and required to process your application.
