NeuroCatalyst Academy — Registration Application

NeuroCatalyst Academy

Registration Application • Place where Black & Brown neurodivergency is loved and celebrated
1
Student
2
Parent/Guardian
3
Emergency
4
Health
5
Interests
6
Documents
7
School & Funding
8
Consent

Part 1 — Student Information

Part 2 — Parent / Guardian Information

Use student's address for Parent/Guardian 1
Need to add Parent/Guardian 2?

Part 3 — Emergency Contacts & Authorized Pickup

Add at least one emergency contact. You can add up to 4 (one at a time).

Part 4 — Health & Safety

Primary Care Physician

Preferred Hospital

This list will still work even if you don't add all contacts listed.

Part 5 — Behavior & Special Interests

We want to support your family's beliefs and practices with care and respect.

Part 6 — Documents & Files

You can email documents to neurocatalystacademy@gmail.com. If you can't send them now, choose Exempt/Not now and we’ll follow up.

Birth Certificate

Will email a copy
Exempt / Not now

Immunization Record (Shot Record)

Will email a copy
Exempt / Not now

IEP / 504 Plan

Will email a copy
Exempt / Not now

Part 7 — Current School Enrollment

Note: Tuition funding does not impact your child's eligibility for enrollment.

Part 8 — Consent & Releases

Media Release

Permission for your child to appear in NCA photos/videos used for school communications and celebrations.

Consent
Do not consent

Field Trip Consent

Permission for local field trips with prior notice. Details will be sent before each trip.

Consent
Do not consent

Medical Consent

I authorize NCA staff to seek emergency medical care for my child if necessary.

Consent
Do not consent

Handbook & Expectations Agreement

Please review our handbook & resources: neurocatalystacademy.org/resources

I have reviewed and agree to the Handbook & Expectations.
Please agree to the Handbook & Expectations.

Enrollment Confirmation

By submitting, I affirm the information provided is accurate to the best of my knowledge.

I agree to submit this application.
Please check “I agree to submit this application.”

Would you like a copy emailed to you?

Yes, email me a copy
If enabled in our mail service, a confirmation/copy will be sent.
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Thank you for enrolling in NeuroCatalyst Academy!

Place where Black & Brown neurodivergency is loved and celebrated.

Submission Receipt

A summary of what you submitted. Keep for your records.
Start a New Application
Questions? Email us at neurocatalystacademy@gmail.com.