Registration

Step 1 of 6

16%

Application must be completed in full to be considered.

Applicant’s name(Required)

Child's Name(Required)

First Middle Last

Nickname

Gender(Required)

Male

Female

Applying for grade

Current grade

Current School

Date Of Birth(Required)

Address(Required)

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

FAMILY INFORMATION

Mother’s name:

Father’s name:

Preferred Name

Home address: (If different from above)

Cell phone

Home phone

Email(Required)

Employer

Employer address

Business phone

Emergency Contact Name

Phone Number

Yes, the emergency contact has permission to pick-up my child.

YES

Are parents married?

YES

If no, who has legal custody?

Name(s) of step-parent(s), if any

Siblings’ names, ages, schools/occupations

Describe any learning issues among other family members

Please write a short paragraph describing your child in his or her home environment including any special talents, interests, and other information you would like to provide.(Required)

SCHOOL HISTORY

School & District

Year(s)

Grade(s)

School & District

Year(s)

Grade(s)

School & District

Year(s)

Grade(s)

Has your child ever repeated a grade?

YES

Which grade?

Why?

Has your child previously attended an educational program?

YES

If yes, when and which program?

Who referred you to Mobile Classroom Solutions?

What Mobile Classroom Solutions Program are you applying to?(Required)

Please describe your child’s specific school needs:

OUTSIDE SERVICES

Has your child been recommended for evaluation for any of the following services? (Check all that apply.)

Tutoring

Counseling

Speech/Language Therapy

Occupational Therapy

Medication

Please list the following information about services your child is receiving or has received.

Tutoring

Provider

Date

Result

Counseling

Provider

Date

Result

Speech/Language Therapy

Provider

Date

Result

Occupational Therapy

Provider

Date

Result

School Services Other

Provider

Date

Result

HEALTH INFORMATION

Mobile Classroom Solutions, Incorporated requires medical information from the diagnosing physician /psychologist to accompany all applications. Mobile Classroom Solutions, Incorporated is motivated to help students with learning difficulties to achieve academic success.

My child has an

IEP

504 Plan

Neither

My child has been diagnosed with

Autism

Dyslexia

ADHD

ADD

Dysgraphia

Other

Pediatrician’s name

Address

Date of last examination

Allergies

Vision/hearing problems

Other medical concerns or issues/Conditions that require specific care or caution

Regular medications taken

We verify that the information provided on this application is correct and complete to the best of our knowledge.

Consent

I agree to the privacy policy. https://mobileclassroomsolutions.com/privacy-policy/

Application must be completed in full to be considered.

FAMILY INFORMATION

SCHOOL HISTORY

OUTSIDE SERVICES

Please list the following information about services your child is receiving or has received.

Tutoring

Counseling

Speech/Language Therapy

Occupational Therapy

School Services Other

HEALTH INFORMATION

We verify that the information provided on this application is correct and complete to the best of our knowledge.

Get ConnectED WITH
MOBILE CLASSROOM SOLUTIONS!

Follow Our Social Media

MCS Quick Links

MCS Resources

Location

Registration

Application must be completed in full to be considered.

FAMILY INFORMATION

SCHOOL HISTORY

OUTSIDE SERVICES

Please list the following information about services your child is receiving or has received.

Tutoring

Counseling

Speech/Language Therapy

Occupational Therapy

School Services Other

HEALTH INFORMATION

We verify that the information provided on this application is correct and complete to the best of our knowledge.

Get ConnectED WITH MOBILE CLASSROOM SOLUTIONS!

Follow Our Social Media

MCS Quick Links

MCS Resources

Location

Get ConnectED WITH
MOBILE CLASSROOM SOLUTIONS!