Unicorn Village Academy


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Unicorn Village Academy

A Life Skills, Academic, & Career Academy serving Youth

14-22 with Neurodiversity and Hidden Abilities

21100 Ruth & Baron Coleman Blvd

Boca Raton, FL 33428

Application for Enrollment

2013-2014 School Year

Application Instructions: Please complete and submit this application.
All information on the application must be complete.
Copies of the following documents must be submitted with this application:
• Copy of birth certificate/social security card
• Child’s current immunizations
• Current report card
• Current IEP or Educational materials 

Return forms to Admissions:

Unicorn Village Academy
3350 NW Boca Raton Boulevard
Suite A-28
Boca Raton, Florida 33431


Student Name:
Sex: Male Female

Birth Date:// Student Age:
Social Security Number:
Student Address:

City: State: Zip:

Student Home Phone:
Cellular Phone:
Alternative Phone:
Email Address:
Student lives with: Parent(s) Guardian(s) (Check One)

If the student is 16 years of age or older, what is the current status of guardianship process:
If the student is 18 years of age or older, who is the legal guardian?

If someone other than the child is guardian, we will require documentation of guardianship before enrollment.

How did you hear about Unicorn Village Academy?
Is the student currently enrolled in school?No Yes               Grade Level:

Name of School (if not in school, last school attended):

School Address:


City: State: Zip:

Date of Last Attendance://

If in school, reason for looking at new school/If not in school, reason for leaving/termination:

Diagnosis/ Classification (s) Received:
Asperger’s Syndrome
High Functioning Autism
Autism Spectrum Disorder
Attention Deficit Disorder
Attention Deficit Hyperactivity Disorder
Non-Verbal Learning Disability
Tourette’s Syndrome
Specific Learning Disability (list)
Sensory Issues (list)
Other (list)
Dates of Initial Diagnosis
Diagnosis done by

Other services your child has received or is receiving (i.e. after school care, summer camp, speech therapy, physical therapy, home tutoring, and home training):
Service: Date: Frequency:
Service: Date: Frequency:
Service: Date: Frequency:


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Social History

UVA is a strength-based Transitional program designed to maximize student potential. Please discuss your child’s relationships with family, friends and school staff. Discuss his/her strengths and interests, likes and dislikes; list significant events which may have precipitated behavior, goals and expectations, hobbies and any other pertinent information. Include you and your child’s goals and expectations. List any sensory issues, “stressors,” or “anxiety producing” factors you are aware of. Please list career interests, social relationships desired, etc. Discuss desired outcomes you would like to see occur. Please be as specific as possible:

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Educational Information

Student’s Name: 
School District: 
County Student’s ID: (if known)

UVA is fully committed to providing quality education to all of our students. The following information is extremely important in order to ensure that your child’s needs are met. Please complete this page with care.

Has your child been involved with early intervention services (birth to 3)? Yes No
Has your child been screened for special education by the public schools? Yes No
Does your child have a current Individual Educational Plan (IEP)? Yes No
If your child does have an Individual Educational Plan (IEP), we should receive a copy of the IEP prior to your child entering school.

Has your child ever received special education services? Yes No
Does your child receive services under Section 504 of the Rehabilitation Act of 1973? Yes No

Please check the services your child has and/or still receives as dictated by their IEP. (Check all that apply)
Speech & Language
Physical Therapy
Inclusion Services
Self Contained Classroom
Orientation & Mobility
Occupational Therapy
Resource Room
Adaptive Equipment
Visually Impaired
Medical Services
Adapted Physical Education

Does your child take medication? (for ADHD, Diabetes, etc.) Yes No
If yes, what medications does your child take and for what purpose?
List Dosage and Frequency:

Does your child wear glasses? Yes No
Does your child wear a hearing aid? Yes No
Are you concerned that your child may have a special need that has not been evaluated yet? Yes No
If yes, please explain:



How does your child communicate?
Verbally using full sentences
Verbally using words or short phrases
Exchange of pictures
Sign language
Voice output device
A combination


Does your child exhibit any self-stimulatory behavior? Yes No

If yes, describe:

Does your child exhibit any challenging behaviors? (ex., self-injury, aggression, etc)
Yes No

If yes, describe:

What are some activities your child enjoys or is good at?

What are some activities your child has difficulty with or does not like?

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To Whom It May Concern:
With this letter, I the undersigned grant permission to Unicorn Village Academy to use Photographs/video footage of my child for marketing and promotional materials (e.g. brochures, slides, Website, advertisements) or for the release to the media.
Student Name:
Student Age:
Parent/Guardian Name:

Parent/Guardian Electronic Signature: (Retype Name)

Student Electronic Signature if over 18 years of age: (Retype Name)

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Unicorn Village Academy

Release of Information

Student Name:
Public School ID (if known):
School Student Last Attended
School Information Released To:
School Official Name/Title:

I hereby request and authorize you to release as indicated above any medical information, educational records, psychological reports, or other pertinent data you may have, or may receive, that would aid in providing appropriate educational services.

All psychological/confidential data will be maintained as such. It will not be transferred to any person/agency without parental permission. Parents will have access to all student records.

Student Name:
Guardian/Parent Electronic Signature:

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All new students seeking entrance into a public or private school in Palm Beach County are required by Florida Statute 1003.22 and School Board policy to present, at the time of entry, valid documentation of (2) health forms:

1. A valid DH 680 (blue form) have received the required immunizations against the communicable diseases as identified by the Department of Health.

A valid DH Form 680 (yellow form) must include:

• The student’s complete name, date of birth, and the name of the student’s parent/guardian.

• All vaccine dates should be listed with the month/day/year.

• Name of the physician or clinic; physician or clinic address; signature (or signature stamp) of the physician, nurse or the physicians authorized designee; or the County Health Department stamp, nurses signature and the date the form was signed and issued. The Florida Certification of Immunization – DH 680 – includes sections for temporary and permanent medical exemptions. Temporary Medical Exemptions must have an expiration date.

2. A valid DH3040 (yellow form) State law requires a health examination by a legally qualified professional. Additional requirements may be determined by local school districts.

Permanent Medical Exemptions must specify which vaccine the student is exempted from and the valid clinical reason for exemption. Permanent Medical Exemptions must be signed by a physician (M.D. or D.O.). Copies of DH 680 can be accepted. If a hardship exists for parents transferring students, according to statute, it is permissible to allow 30 school days for the transfer of records.

The Certificate of Religious Exemption, DH Form 681, is available only through the Palm Beach County Health Department. It is not available from private physicians.

Only an original DH Form 681 will be accepted at school sites.

General Recommendations on Immunization - Special Notice for Data Processors Documentation of Immunization……… DH Form 680 (July, 2006; January 2007; August 2007; July 2008)
• Part A (Certificate of Immunization for K-12 – DOE Code 1)
• Part A (Certificate of Immunization for 7th Grade requirement - DOE Code 8)

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Financial Information
Application and Request for Financial Aid

Parent/Guardian Name:
Student Name:

Are you receiving the McKay Scholarship? Yes No

List details:
Are you requesting information about the McKay Scholarship? Yes No

List child’s last school attended:
List attendance dates:
Are you requesting Financial Aid? Yes No

Requests for Financial Aid require a meeting with the Financial Aid Committee. If you are interested in a meeting, please sign below.

I, (name) am requesting a meeting with the Financial Aid committee to discuss funding issues for my child (child’s name).

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Credit Cards Accepted by Phone

Make Checks Payable to:
Unicorn Village Academy
21100 Ruth & Baron Coleman Blvd., Suite 200
Boca Raton, FL 33428

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