GATE Academy
Application for Admission
GATE Academy · 1 St. Vincent Drive, San Rafael CA 94903 · www.gateacademy.org · P: 415-491-4700 · F: 415-491-4701

Application for Admission

Student Information
Last
First
Nickname
Gender
Home Phone
Street Address
City
State
Zip Code
Date of Birth
Place of Birth
Child's Ethnicity (Optional)
Family Information
Parent/Guardian Full Name
Parent/Guardian Full Name
Address (if different from above)
Address (if different from above)
Home Phone
Home Phone
Cell Phone
Cell Phone
Email
Email
Primary Language
Primary Language
Occupation
Occupation
Employer
Employer
Business Phone
Business Phone
Relationship to child: Birth Parent   Guardian   Adoptive Parent (child's age at adoption) ______   Other ____________
Check all that apply: Married  Partnered  Separated  Divorced  Single  PG1 Deceased  PG2 Deceased  PG1 Remarried  PG2 Remarried
Other children in the family
Name
Gender
Age
Present School & Grade
Applying to GATE?
Name
Gender
Age
Present School & Grade
Applying to GATE?
Relatives who have attended GATE Academy
Name
Relationship
Child's Academic Information
Current School
City/State
Phone Number
Beginning Date of Attendance
Present Grade/Class
Teacher's Name
Director's Name
Previous schools attended (most recent first)
School
Year
Grade(s)
Teacher
School
Year
Grade(s)
Teacher
School
Year
Grade(s)
Teacher
Has your child ever:
Previously applied to GATE Academy? (Grade & Academic Year)
Skipped a grade? (Grade & Academic Year)
Taken a cognitive (IQ) test? (Name of test and date(s)) — Please provide GATE Academy with a copy of the test results.
Testing & Diagnoses
Please share any information that will help us better know your child. This might include health concerns, learning differences, tutoring, accelerated programs, family circumstances, previous assessments, educational evaluations, etc.
Been diagnosed with a learning difference? Yes    No
Had a neuropsychological evaluation by a psychologist? Yes    No
Been tested or diagnosed with a neuropsychological, neuro-motor and/or behavioral condition, dysfunction or challenge? Yes    No
If yes, please explain:
Parent Questionnaire
What interests you most about GATE Academy?
How have your child's needs gone unmet in other educational settings?
What are your child's strengths, talents, and/or abilities (plays an instrument, sings, draws, collects, enjoys computers, etc.)?
What do you consider to be your child's academic and social/emotional challenges? Where is growth needed?
What three adjectives would you use to describe your child? Please explain.
How would you like to be involved in the GATE Academy community?
How did you learn about GATE Academy?

School Fair   Current GATE Academy Family   Web Search   Advertisement   GATE Academy Alumni   Summer Camp at GATE Academy   Referral (Friend / Physician / Psychologist)   Other
Permission & Signatures
I/We give permission for my/our child to be administered the Wechsler Intelligence Scale for Children (WISC-IV) or Stanford-Binet (for children younger than six years old). I/We authorize GATE Academy admissions staff to discuss submitted outside test results with the test administrator. I understand all communication between the school and the tester will remain confidential. I certify that my child was not exposed to the test within the last 18 months, and that no materials were used to practice answers. Signatures of custodial parent(s)/guardian(s) are required.
Signed
Signed
Date
Date
Person(s) financially responsible
Billing address (if different from parent/guardian)
PLEASE ENCLOSE YOUR NON-REFUNDABLE APPLICATION AND TESTING FEE OF $385.00 WITH THIS APPLICATION.
IF OUTSIDE TESTING RESULTS ARE SUBMITTED, THE APPLICATION FEE IS $85.00.
CHECKS MAY BE MADE PAYABLE TO GATE ACADEMY
Please mail application to:
GATE Academy · 1 St. Vincent Drive · San Rafael, CA 94903
Please attach a photo of your child