Follow Us: SearchSearch

    LUA Application

    Home · Programs · Chicago · Urban Academy-Chicago · Forms · LUA Application
    Please fill out the following application completely and accurately. Required fields must be completed or your application will not be accepted. Once your application has been submitted, you will be contacted for an interview by the school Director.

    Please note that all phone number and e-mail fields must be completed. If you do not have a phone number, please enter 555-555-5555. You must have at least one valid e-mail address in order to complete this form, which may be entered for both the student and the guardian. If you do not have at least one valid e-mail address, you may sign up for one for free at www.mail.yahoo.com.

    The next quarter begins January 4, 2010.
    Student First Name
    Student Last Name
    Birth Month
    Birth Date
    Birth Year
    Home Phone Number
    Student Cell Phone
    Street Address
    Apartment / Unit Number
    City
    Zip Code
    Student E-mail
    Guardian First Name
    Guardian Last Name
    Relationship to Student
    If other, please specify
    Does this guardian reside with the student?
    Guardian's Occupation
    Guardian's Highest Level of Education
    Guardian's Primary Language
    If other, please specify
    Was this guardian born in the United States?
    If not, in which country was this guardian born?
    Work Phone Number
    Guardian Cell Phone
    Guardian E-mail
    Guardian First Name
    Guardian Last Name
    Relationship to Student
    If other, please specify
    Does this guardian reside with the student?
    Guardian's Occupation
    Guardian's Highest Level of Education
    Guardian's Primary Language
    If other, please specify
    Was this guardian born in the United States?
    If not, in which country was this guardian born?
    Work Phone Number
    Guardian Cell Phone
    Guardian E-mail
    Emergency Contact (must be different than guardian)
    Relationship to Student
    Emergency Contact Phone Number
    Alternate Phone Number
    Last School Student Attended
    Number of Credits Earned
    GPA
    The student requires special accomodations per (check all that apply)
    Please describe accomodations
    The student has had the following disciplinary problems (check all that apply)
    Student's Ethnicity
    Student's Race (choose all that apply)
    If other, please specify
    What is the student's first language?
    If other, please specify
    Was the student born in the United States?
    If not, in which country was the student born?
    Student's Gender
    Student's Faith Affiliation
    If other, please specify
    Annual Household Income
    Number of people living in household, including student
    Will you be seeking reduced tuition?
    Will the student assist with tuition payments?
    Is the student employed?
    Does your family receive public assistance?
    If so, please specify
    Does the student receive reduced lunch?
    Has the student been incarcerated or have a juvenile record?
    Is the student on probation?
    Is the student a parent or an expecting parent?
    Does the student have any medical (mental / physical) diagnoses?
    Does the student see a mental health professional regularly?
    If you answered yes to any of the above questions, please explain
    What does the student intend to do after graduating from high school?
    If other, please specify
    What strengths / positive attributes does the student have?

    Contact Us | © LYDIA: Strengthening Children & Families
    Powered by iMinistries, a Church Website Content Management System.