Admissions Application

Click here to download and mail or fax in your application

Parent/Guardian Information

Name:

Address:

Phone:

Email Address:

Student Information

Name:

Adopted: Yes No

Age Adopted:

Date of Birth:
Age:

Height: (in Inches)
Weight:

SS#

With Whom is the Child Currently Living?

Name:

Relationship:

Why do you think your son needs to be admitted to an emotional growth school?

Referral Source Information:

Please Select:

Additional Inforamtion (If other selected or search engine used and keywords, or referral link from another website):

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If you were referred by a specific person please complete the following:

Person who referred you:

Address:

Phone

©EAGLE PINES ACADEMY 2005 • P.O. Box 629 • Smithville, TX 78957 • 866-678-7463 •Tel: 512-237-2055 • Fax: 512-237-2840 • © 2005 Website design by Adbiz. Eagle Pines Academy admits students of any race, color, national origin and ethnic origin to all the rights, privileges, programs and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national origin and ethnic origin in administration of its educational policies, admission policies, scholarship and loan programs, and athletic and other school-administered programs.