ALLIES - Student Information Form

ALLIES Academy for Literacy, Learning & Innovation Excellence Student Information Form

Complete and submit the form below and you will receive an email or phone call if we have further questions regarding the information on this form. If we believe ALLIES and the Take Flight Therapy program may be a good fit for your student and we have space available you will receive a phone call or email. If enrollment is full you will be placed on a waitlist and we may contact you closer to the following school year. (must complete all fields)
Where did you hear about ALLIES?*
Student Name*

First NameLast Name
Parent / Legal Guardian Name*

First NameLast Name
Parent E-mail*
Use an email you check regularly
Phone Number:*

Area CodePhone Number
Child's Birth Date:*

MonthDayYear
Student's Gender

MaleFemale
Grade child is entering NEXT Fall: 2025-2026*
Grade your student will enter next school year
Has your child ever repeated a grade?*

YesNo
Current District of Residence*
Please include the number, example D49
What school is your child currently attending?*
Has your child been receiving an intervention "in school" or through outside tutoring?*
If you answered YES to the question above: What program have they been receiving and for how long and how often? If you answered NO above, please put NA.*
Examples: Take Flight - 2 years - 2x week , Wilson - 1 year - 4x week, Susan Barton 3 years - 3x week, Language! - 2 years - 3x week, Linda Mood Bell - 1 year - 2x week, SIPPS - 1 year - 4x week, etc.

Does your child currently have any of these individualized plans? *

	Created in D49	Created in other school district	NA
MTSS plan (RtI)
READ Plan (K-3 Literacy plan)
ALP (Advanced Learning Plan) or (Gifted and Talented Identified)
Behavior Plan
Health Plan
other

If other is marked above, please explain...
If your child has any plans (above), they must be scanned and emailed to our Administrative Secretary, Mrs. Sandi Esparsen @ sandra.esparsen@d49.org (or a copy may be sent to Sandi Esparsen @ ALLIES 6275 Bridlespur Ave. Colorado Springs, CO 80922) BEFORE this form will be addressed. Until then your information will be INCOMPLETE.

How can we best accommodate for your child? Please identify any of the following for which you have a concern. * If "Official Diagnosis or Academic Identification" box is checked, the report must be scanned and emailed to our Administrative Secretary, Mrs. Sandi Esparsen at sandra.esparsen@d49.org (or a copy may be sent to Sandi Esparsen, ALLIES 6275 Bridlespur Ave. Colorado Springs, CO 80922) to provide evidence of the diagnosis. Until then your information will be INCOMPLETE. * If "I see signs or Teacher or School has commented" box is checked, you will receive a phone call to set up a screener to determine if ALLIES is a good fit for your child - unless this was completed by D49 already.*

	Official Diagnosis or Academic Identification	No official diagnosis but as a parent I see signs of the following	No official diagnosis but the Teacher or School has commented on the following	NA
Dyslexia
Dysgraphia
ADD/ADHD (Attentional Issues)
Anxiety
Health Issue
Other Diagnosis

If ADD / ADHD or any form of 'attentional issues' are addressed please type a few sentences below telling us how it is addressed. If it is not addressed please type 'unaddressed'.
If 'Health Issue' or 'Other Diagnosis' is marked above, please explain...
If your child's Diagnosis or Health Issue above is supported by any form of medication, please explain below. Otherwise type NA.*

Please Identify any of the scenarios you have experienced:*

	Yes, my child has received	No, this does not apply to my child
'Letters of Concern' regarding attendance
Behavior Referrals
Suspension
Homeschooling or attendance in an alternate school (Charter School, School of Choice, etc.) in previous years

Please type below: If Behavior Referrals or Suspension was marked above please let us know what these incidents were comprised of so that we can best support your student
Please type below: additional comments or any questions you have for us
Information Agreement
Student Information Agreement

1. My child's current school / teacher may be contacted to obtain all academic or behavioral records, plans and/or comments. If you send us this form you are agreeing to this.

2. I will provide a copy of all items below (if applicable) to sandra.esparsen@d49.org at ALLIES - BEFORE the form is addressed.
- Report for official diagnosis / official identification
- READ Plan
- Reading Scores from DIBELS, AIMSWEB or Similar Test (if we are screening)
I have read, understood, and accepted the agreement for student information.
Student Information Form Agreement
The Academy for Literacy, Learning and Innovation Excellence (ALLIES) is a 100% School of Choice facility and we believe that students interested in our school are seeking continued full time enrollment for three years (the duration of the Take Flight Therapy program). Once you have completed the form, and confirmed all information herein is accurate, please check the "I agree" submit button below. Upon submitting this form (and sending ALL additional documentation required) you understand that your child is being added to the Academy for Literacy, Learning and Innovation Excellence waiting list based on the assumption that all information provided by you is truthful. If the school should subsequently determine that one or more of the answers provided were not truthful, or information provided at a later date indicates a child's additional need(s), it reserves the right to revoke your child's spot on the waiting list and to potentially prevent or remove future enrollment opportunities. Thank you for your interest in our school.

I AGREE. I have read, understood, and accepted the Student Information Form Agreement for ALLIES and will send all documentation immediately.
Thank you for your interest in our new and innovative school.

We want to be your ALLIES in Literacy and Learning!

Reminder:

Complete and submit the form above and you will receive an email or phone call between now and July 2024 to direct you to the next steps in the process of enrollment IF we believe ALLIES and the Take Flight intervention are a good fit for your student and IF space becomes available.

(please complete all fields)
Should be Empty:

ALLIES Academy for Literacy, Learning & Innovation Excellence Student Information Form

Information Agreement

Student Information Form Agreement