5 Week Remediation Summer Program Application

Student Name

First

Last

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Present School

Grade (Entering Fall of Current Year)

How did you hear about our summer program?

Name of Parent/Guardian #1

First

Last

Relationship

Address of Parent/Guardian #1

Address Line 1

Address Line 2

City

State

Zip Code

Email Address of Parent/Guardian #1

Home Phone Number of Parent/Guardian #1

Cell Phone Number of Parent/Guardian #1

Work Phone Number of Parent/Guardian #1

Name of Parent/Guardian #2

First

Last

Relationship

Address of Parent/Guardian #2

Address Line 1

Address Line 2

City

State

Zip Code

Email Address of Parent/Guardian #2

Home Phone Number of Parent/Guardian #2

Cell Phone Number of Parent/Guardian #2

including of to

Work Phone Number of Parent/Guardian #2

Please attach results of previous educational testing, including current levels of academic functioning and current achievement test scores.

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Please attach a brief letter from a current teacher regarding your child's educational needs.

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Please upload the report of a recent psychological testing, including eligibility diagnosis or clinical diagnosis.

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Please attach any additional that you feel should be provided to Lake Michigan Academy.

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Office Hours:

7:30 AM - 4:00 PM

Lake Michigan Academy does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, height, weight, physical or mental ability, veteran status, military obligations, and marital status.

Lake Michigan Academy and Turning Pages Tutoring
2428 Burton St SE
Grand Rapids, MI 49546
Lake Michigan Academy: (616) 464-3330
Turning Pages Tutoring: (616) 243-7323
Fax: (616) 285-1935
admin@lakemichiganacademy.org

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