The Diener School Application - The Diener School

ADMISSIONS

The Diener School Application

Thank you for taking the time to Apply to The Diener School.

Step 1: Start the application. As you enter your information, it is automatically saved. You will be able to come back and add, edit, or change any information for up to 30 days.

IMPORTANT: When you select "save and continue later", you will be asked to provide an email address to receive an email with a special link to return to the form you can use to jump back to where you left off. It does expire after 30 days! Be sure to check your spam if you don't get it immediately.

Step 2. Submit your child's application: Once you complete and submit your paid application, you will receive a confirmation email with a PDF of your application.

"*" indicates required fields

Step 1 of 11

Let's get started. Please provide the name and email address of who is filling out the form. This is the email address of the person who wants to receive a copy of the final submitted application and receipt of payment.

Please check to start the application.*

Yes, I'm ready to start.

Name*

First Last

Email*

Enter Email Confirm Email

The Diener School Admissions Policy Statement

Thank you for taking the time to apply to The Diener School. The admissions process requires a great deal of open yet confidential communication between families, schools, professionals and Diener staff. In the interest of ensuring an optimal educational experience for our students, we require that all questions must be answered with complete honesty and all of the information required during the admissions process must be disclosed. This includes any significant change with the applicant’s medical, social/emotional and/or educational status from the date your application is received until your child’s first day of school at Diener. All information collected and created as part of the application process are the property of the school and families will not be provided copies or access to this information.

The Diener School reserves the right to deny admission or remove for expulsion if there are any material disclosures that were not made.

By signing this document you agree to the above statement.

Parent or Guardian*

First Last

Date of Application Submission*

Month

Day

Year

Signature

Release of Information

I authorize the release of information regarding my child to The Diener School either through written or verbal communication. This release includes, but is not limited to, school reports, transcripts, therapeutic services, assessments, testing/evaluations, and treatment plans from medical, educational and therapeutic professionals who are currently working with or have worked in the past with my child. This release will be considered active through the admissions process as well as ongoing if the student is accepted and enrolled at Diener. All information disclosed will be considered confidential.

Parent/Guardian Name*

Date of Application Submission*

Month

Day

Year

Parent/Guardian Signature*

Applicant Information

Applicant's Name (Student)*

Date of Birth*

Month

Day

Year

Age*

Current Grade*

Current School

Are you working with an Educational Consultant?*

Yes

Name of Educational Consultant*

Phone*

Educational Consultant's Email*

Family Information

Parent/Guardian

Parent/Guardian 1 will be the one to receive an email confirmation once the application is paid and submitted.

Parent/Guardian 1*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone (Cell)*

Phone (Home or Office)

Parent/Guardian 1 Email*

Occupation & Employer*

Parent/Guardian 2

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone (Cell)

Phone (Home or Office)

Occupation & Employer

Do you have another Parent/Guardian to add?

Yes

Parent/Guardian #3

Parent/Guardian 3

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Contact Info

Phone (Cell)

Phone (Home or Office)

Occupation & Employer

Sibling Information

Siblings

If your child has any siblings add them here. Please add an additional row per sibling by clicking the plus sign.

Sibling Name

Age

Current School

Grade

General Family Question

Are there any special family circumstances you would like us to know about?

Education Information

Current School Information

Please describe your child's current classroom.*

General

Special

Hybrid

Home School/Pod

Did your child attend another school in the past?*

Yes

Please describe your child's previous school history.

Does your child have an IEP, 504, or other learning profile?*

Yes

Does the applicant have any 1:1 support at any point during their school day?*

Yes

Please describe the 1:1 support.

Medical and Developmental Information

Birth Information*

Full Term

Premature

Adopted

How many weeks at birth?

Age at time of Adoption

Is your child taking any medications?*

Yes

Please list all medication(s).

Prescribing Doctor

Contact Information

Does your child have any allergies, medical conditions, or dietary restrictions? If so please describe.

Professionals

Has your child seen any of the following professionals?

Developmental Pediatrician*

Yes

Name of Developmental Pediatrician

Contact information (phone and email)

Has your child received a diagnosis from your Developmental Pediatrician?

Yes

What was the Developmental Pediatrician's diagnosis?

Psychiatrist*

Yes

Name of Psychiatrist

Contact information (phone and email)

Has your child received a diagnosis from the Psychiatrist?

Yes

What was the Psychiatrist's diagnosis?

Neurologist*

Yes

Name of Neurologist

Contact information (phone and email)

Has your child received a diagnosis from the Neurologist?

Yes

What was the Neurologist's diagnosis?

Assessment Information

Has your child received or is in the process of receiving any of the following assessments? Please add an additional row if necessary by clicking the plus sign. Please put N/A if the question does not apply.

Neuropsychological Testing

Date

Evaluator

Contact Info

Diagnosis

Educational Testing

Date

Evaluator

Contact Info

Diagnosis

Developmental Assessment

Date

Evaluator

Contact Info

Diagnosis

Speech and Language Evaluation

Date

Evaluator

Contact Info

Diagnosis

Occupational Therapy Evaluation

Date

Evaluator

Contact Info

Diagnosis

Other

Date

Evaluator

Contact Info

Diagnosis

Therapeutic Information

Has your child seen any of the following professionals? Please add an additional row if necessary by clicking the plus sign. Please put N/A if the question does not apply.

Social Skills Group

Name of Provider

Contact Phone & Email

Setting: (Private or School)

Speech Language Therapist

Name of Provider

Contact Phone & Email

Setting (Private or School)

Occupational Therapist

Name of Provider

Contact Phone & Email

Setting (Private or School)

Academic Tutor

Name of Provider

Contact Phone & Email

Setting (Private or School)

Psychologist or Therapist

Name of Provider

Contact Phone & Email

Setting (Private or School)

Other

Name of Provider

Contact Phone & Email

Setting (Private or School)

General Information

Please describe your child's academic strengths.

Please describe your child's academic challenges.

How does your child relate to peers and adults?

Does your child have any special interests or participate in any extracurricular activities?

Please describe your child's sensory and/or attentional needs.

Does your child demonstrate behavioral challenges at home? Please describe.

Does your child demonstrate behavioral challenges in school? Please describe.

Why do you think your child will benefit from attending The Diener School?

Is there anything that you would like to explain to the admissions committee or provide additional information that hasn't been covered in this application?

Required Documents

Please note on this page only if you click on "save and continue later" any uploaded documents will not be saved for security purposes until your application is submitted.

A recent photo of your child*

Accepted file types: jpg, pdf, png, jpeg, Max. file size: 300 MB.

Please upload all assessments and reports as described in your application.

Drop files here or

Accepted file types: pdf, jpg, png, doc, Max. file size: 500 MB.

Please upload your child's most recent report card and IEP or 504 as applicable.

Drop files here or

Accepted file types: jpg, png, pdf, doc, Max. file size: 500 MB.

Additional Application Information

1. Once you submit the application, you will not be able to edit your application.
2. You will receive a confirmation email with a PDF of your application.
3. A teacher recommendation form will be emailed to you directly.
4. Your application will not be considered "complete" for review until all documentation has been received.
5. If you need to send additional forms/documents or have any follow-up questions, please contact Lois McCabe directly at Lois@thedienerschool.org or call (301) 299-4602.

Application Fee & Billing Information

The 2023-2024 Application is a non-refundable fee of $100.

Billing Name*

First Last

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Credit Card*

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Diener 2023-2024 Application Fee*

Price:

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Comments

This field is for validation purposes and should be left unchanged.

ADMISSIONS

Let's get started. Please provide the name and email address of who is filling out the form. This is the email address of the person who wants to receive a copy of the final submitted application and receipt of payment.

The Diener School Admissions Policy Statement

Release of Information

Applicant Information

Family Information

Parent/Guardian

Sibling Information

General Family Question

Education Information

Current School Information

Medical and Developmental Information

Professionals

Assessment Information

Therapeutic Information

General Information

Required Documents

Please note on this page only if you click on "save and continue later" any uploaded documents will not be saved for security purposes until your application is submitted.

Additional Application Information

Application Fee & Billing Information

The Diener School | Motivating Minds, Inspiring Capabilities

How You Can Reach Us

At Your Fingertips

Stay Connected

ADMISSIONS

Let's get started. Please provide the name and email address of who is filling out the form. This is the email address of the person who wants to receive a copy of the final submitted application and receipt of payment.

The Diener School Admissions Policy Statement

Release of Information

Applicant Information

Family Information

Parent/Guardian

Sibling Information

General Family Question

Education Information

Current School Information

Medical and Developmental Information

Professionals

Assessment Information

Therapeutic Information

General Information

Required Documents Please note on this page only if you click on "save and continue later" any uploaded documents will not be saved for security purposes until your application is submitted.

Additional Application Information

Application Fee & Billing Information

The Diener School | Motivating Minds, Inspiring Capabilities

How You Can Reach Us

At Your Fingertips

Stay Connected

Required Documents

Please note on this page only if you click on "save and continue later" any uploaded documents will not be saved for security purposes until your application is submitted.