New Student Application

The Burkard School accepts rolling admissions throughout the school year.

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The Burkard School Admissions Form

Please fill out this form as completely as possible.If necessary, you can save your progress (bottom of the page) and finish at a later time.All information you supply is kept private and confidential. We will not share this information with anyone outside of The Burkard School organization.

Student’s Personal Information
First name*
Last name*
Middle name
Nick name
Gender*
- Female
- Male
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Phone
Applying for grade:*
Height
Weight
Parent/Guardian Information
1st Parent or Guardian Name*
First Last
Address same as applicant's?*
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Occupation
Employer
Home phone*
Cell phone*
Work phone
Email*
Enter Email Confirm Email
Relation to applicant*
2nd Parent or Guardian Name
First Last
Address same as applicant's?
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Occupation
Employer
Home phone
Cell phone
Work phone
Email
Enter Email Confirm Email
Relation to applicant
Additional Parental Information
Parents’ marital status
- Married
- Separated
- Divorced
- Widowed
- Single
- Domestic Partners
Legal custody
- Sole custody
- Joint custody
Physical custody
- Sole custody
- Joint custody
Family Information
Complete the following for all additional members of the applicant's household
Name
First Last
Date of birth
Gender
- F
- M
Relation to Applicant
Name
First Last
Date of birth
Gender
- F
- M
Relation to Applicant
Name
First Last
Date of birth
Gender
- F
- M
Relation to Applicant
Name
First Last
Date of birth
Gender
- F
- M
Relation to Applicant
Name
First Last
Date of birth
Gender
- F
- M
Relation to Applicant
Number of languages spoken in the home
Please list the languages spoken in the home
What is the primary language spoken in the home?
Educational History
Current school name
Current grade
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
With respect to your child’s current grade, please describe his/her greatest achievements and most significant challenges.
Has the applicant attended any additional schools?*
Please include all schools attended from PreSchool on.
- Yes
- No
Previous Schools
Fill in the following information for all previously attended schools
School Name
School Address
Street Address Address Line 2 City State ZIP Code
Grades attended
School Name
School Address
Street Address Address Line 2 City State ZIP Code
Grades attended
School Name
School Address
Street Address Address Line 2 City State ZIP Code
Grades attended
School Name
School Address
Street Address Address Line 2 City State ZIP Code
Grades attended
School Name
School Address
Street Address Address Line 2 City State ZIP Code
Grades attended
Behavioral and Educational Background
Personality*
Please describe your child’s personality (i.e. social interactions, motivators, general attitude, habits).
Strengths*
What are your child’s strengths?
Hobbies and interests*
What are your child’s hobbies and interests?
Academic Skills and Challenges*
Please describe your child’s academic skills and challenges.
Student Citizenship Skills and Challenges*
Please describe your child’s student citizenship skills and challenges. (i.e. ability to sit at a desk, raise a quiet hand, participate in group lessons, etc.)
Communication skills*
Please describe your child’s communication skills.
Self help skills*
Please describe your child’s self help skills (including eating, dressing, bathing, sleeping, toileting).
Behavior*
Please describe any disruptive or maladaptive behavior your child exhibits. Include whether you see those behaviors at home or at school. Please describe your child’s behavior when he or she is in the “yellow” zone as well as in the “red” zone.
Behavior Frequency*
How often does your child exhibit the behaviors described above?
Triggers*
What are some of the triggers that can result in challenging behavior for your child?
Motivators*
Are there special privileges that are motivating for your child? If so, what are they?
Social relationships*
How does your child relate to family members? Friends? School faculty? Strangers?
Community interactions*
Does your child participate in community groups such as soccer, camp, etc? If so, please describe those interactions.
Optimal learning environment*
Describe what you feel is the optimal learning environment for your child.
Areas of greatest need*
What are your child’s areas of greatest need?
Areas of concern*
Are there additional areas of concern of which we should be aware?
Additional information*
What else would you like us to know about your child?
Behavior and Personality Checklist
Please remember that your accurate responses are in service of being able to determine the right placement for your child.
My child displays:
Please rate on a 1-5 scale for what has been true for your child in the past 6 months
Tactile sensitivity | Reports that things “feel funny” and/or has specific preferences for clothing or blankets of a certain feel*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Tactile sensitivity | My child’s tactile sensitivity causes him or her regular distress or disruptions to his/her day.
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Auditory sensitivity | Reports that sounds bother him or her, has difficulty screening out noises*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
My child’s auditory sensitivity causes him or her regular distress or disruptions to his/her day.
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Orientation | Not orientated to what is going on in the moment, in their own world for the moment.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
My child tends to be in his/her own world especially during non-preferred activities.
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Gross motor challenges | Riding a bike, playing sports, bumping into things*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Fine motor concerns other than writing*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Easily tired, little stamina in physical activity*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Poor ability to read facial or behavioral cues of others*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Inflexible | Believes rules are black and white, intolerant of changing rules or rules not meeting expectations.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Finds it difficult to bounce back when upset*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Easily frustrated | Limited ability to tolerate feelings of frustration without acting out.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Aggression towards objects | Throws things, knocks over furniture, but does not aim at persons.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Verbal aggression | Name calling, inappropriate/rude language, insults, antagonism.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Lower level physical aggression towards peers | May hit, kick, scratch, bite but does not result in significant physical injury.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
How many times per week might your child exhibit this behavior?
- 1
- 2
- 3
- 4
- 5 or more
Lower level physical aggression towards adults | May hit, kick, scratch, bite but does not result in significant physical injury.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
How many times per week might your child exhibit this behavior?
- 1
- 2
- 3
- 4
- 5 or more
Higher level physical aggression to peers | Results in injury needing medical attention.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
How many times per week might your child exhibit this behavior?
- 1
- 2
- 3
- 4
- 5 or more
Higher level physical aggression to adults | Results in injury needing medical attention.*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
How many times per week might your child exhibit this behavior?
- 1
- 2
- 3
- 4
- 5 or more
Meltdowns | Experiences meltdowns that may include lack of awareness of what they are doing, loss of control*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
How many times per week might your child exhibit this behavior?
- 1
- 2
- 3
- 4
- 5 or more
Rigidity, inflexibility of thinking*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Has significant fears or phobias that exceed actual threat and interfere with daily activities*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Has difficulty leaving preferred activity*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Struggles with transitions to the point of interfering with daily activities*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Personal space violations*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Excessive off topic comments*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Excessive interruptions*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Difficulty in seeing another person’s perspective*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Fidgety – cannot sit still*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Physical regulation challenges*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Emotional regulation challenges*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Refusal to attend and/or leave school*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Difficulty attending during instruction*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Needs one-on-one support to complete tasks*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Requires frequent redirection for activities that they have the skill and knowledge to complete*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Tests boundaries more than others his/her age*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Has trouble starting tasks*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Has trouble finishing tasks*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Easily overwhelmed*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Disruptive*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Very sensitive to slights or comments*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Cries easily*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Clingy*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Worries about academic performance disproportionate to skills*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Is frequently sad*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Is frequently withdrawn*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Is frequently irritable*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Expresses hopelessness*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Express not wanting to be alive, that they would be better off in the next life, talks of self harm*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Acts in a way that may harm self*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Expresses sense of worthlessness*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Difficulty concentrating except in most preferred activities (like screens)*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Has stopped enjoying activities that they used to like (with the exceptions of an activity that they have grown out of)*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Uses technology devices to self-regulate*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Has had a recent drop in grades*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Recent changes in friendships*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Wants to leave the classroom or school frequently*
- 1 Strongly Disagree
- 2 Disagree
- 3 Somewhat Disagree
- 4 Agree
- 5 Strongly Agree
Please check all the words that describe your child regularly
- Bright
- Immature
- Easily frustrated
- Sits out
- Confident
- Self-disciplined
- Social
- Distracting
- Courteous
- Hurtful
- Shy
- Passive
- Distractible
- Withdrawn
- Popular
- Assertive
- Organized
- Negative
- Leader
- Restless
- Participates
- Funny
- Irritable
- Focused
- Physical
- Creative
- Articulate
- Does not follow instructions
- Resilient
- Dependent
- Gives up
- Intense
- Calm
- Unmotivated
- Inattentive
Additional information
Is your child on a special diet?
- Yes
- No
Description of special diet
Allergies
Please list any allergies to medications, foods, animals, etc.
How did you hear about The Burkard School?
Thank You
Upon successful completion of this application, you will be taken to a confirmation page and sent a copy of your application via email. If you do not receive this confirmation message, your application did not go through. Please check and see if any required information was omitted, and resubmit.

Save and Continue Later

A new independent K-8 school for bright children who need extra support with self-regulation, executive functioning, and/or social-emotional learning in the classroom.

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Contact

New Student Application

The Burkard School Admissions Form

Student’s Personal Information

Parent/Guardian Information

Additional Parental Information

Family Information

Educational History

Previous Schools

Behavioral and Educational Background

Behavior and Personality Checklist

My child displays:

Additional information

Thank You

Want More Information?