Registration - Midwest Elite Preparatory Academy

Step 1 of 6

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Student Information

Name*

First Middle Last

Date of Bith*

Age*

Gender*

Male

Female

Permeant Home Address*

Street Address Address Line 2 City State ZIP / Postal Code Country

Education

School student is currently attending.

School Name

School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

School Phone

Teacher/Counselor

First Last

Type of School

Independent

Private

Public

Online

Charter

Homeschool

Last Grade Level Completed

1st Grade

2nd Grade

3rd Grade

4th Grade

5Th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

N/A

Has student graduated from High School?*

Yes

When is expected date of graduation?*

Have you taken either of the follwing?

SAT

ACT

Neither

When did you take it?*

Please give at least one date

General Information

How will you pay for tuition?

Private Pay

ESA (Education Savings Accounts)

Scholarship

With whom does the applicant live?*

Mother

Father

Both Parents

Other

Are the student’s parents/guardians divorced or separated?

Divorced

Separated

Who is the custodial parent of the student?*

A custody agreement must be provided.

Mother

Father

Other

Who should receive the financial statements?*

Mother

Father

Both Parent

Other

Parent/Guardian Information

Relationship to Student*

Mother

Father

Aunt

Uncle

Cousin

Sibling

Grandparent

Legal Guardian

Primary/Parent Guardian Name*

Prefix First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Mobile Phone*

Email*

Place of Employment

Position/Occupation

Business Phone

Individual Student Needs

Questions must be answered for all students.

Midwest Elite Preparatory Academy offers various support services to its students; it is necessary to answer the following questions to determine your child’s needs and if our staff can meet them. Please be as detailed as possible and use the back of this form if additional room is needed.

Has student ever been evaluated by a Psychologist or Neuro-Psychologist within the past 5 years?*

Yes

Psychologist or Neuro-Psychologist Results*

RESULTS OF ANY TYPE of Neuro-Psychologist or Educational Evaluation must be provided in order to review application

Does the student have an identified learning difference?*

Yes

What is the identified learning difference?*

Has the student ever had an IEP or 504 Plan?*

Yes

Upload a copy of the IEP or 504 Plan

Max. file size: 40 MB.

Has student ever been provided accommodations in the classroom or on standardized testing?*

For example: extra time, guided reading, etc

Yes

File Upload

Please provide documentation

Max. file size: 40 MB.

Does the student have a chronic medical condition such as diabetes, seizure disorder, severe allergies or mental health disorder?*

Yes

Please explain*

Has the student ever been retained?*

Yes

When and what is the student’s original grade?*

Does the student take any medication on a regular basis?*

Yes

Please list any medication.*

Signature & Agreement

Acknowledgment*

I acknowledge that the information presented on this application is complete. Correct and truthful, and I am willing to abide by the rules and regulations set forth in MEPA. If anything is found to be untrue, MEPA reserves the right to revoke any offer of admission and subsequently remove the student from the academy without refund and enforce the financial agreement.

I agree

Do you require one or two signatures*

One

Two

Signature of Primary Parent/Guardian

Signature of Additional Parent/Guardian*

Payment can also be made via paid by

Cash
Cashapp ($midwestelite)
PayPal
Money order -made out to Midwest Elite Preparatory Academy

Application feee

Price:

Credit Card

Name

This field is for validation purposes and should be left unchanged.

Application: 2023-2024 School Year

Student Information

Education

General Information

Parent/Guardian Information

Individual Student Needs

Signature & Agreement