2022-2023 DBA Application - Dietrich Bonhoeffer Academy

Family Information

Student Name *

First

Middle

Last

Date of Birth *//

Academic Grade for 2022-2023 *

5th
6th
7th

Parent 1 Name *

First

Last

Profession

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent 2 Name

First

Last

Profession

Phone

Email

Check box if same address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you planning on applying for any financial aid?

Yes
No

Student Profile

Current School *

Grades Attended

Previous School

Grades Attended

Which of the following best describes your child's academic grades in recent years?

Please describe your child's strengths as a student:

Please describe your child's extracurricular activities and/or interests:

Has your child ever been diagnosed with a learning disability or received accommodations for a learning difference?

Yes
No

If yes, please explain the nature of the diagnosis and/or the accommodations received:

Has your child had any behavioral or other issues that have impacted their ability to function in the classroom?

Yes
No

If yes, please explain:

Please share any additional information that will be helpful in planning your child's educational program: