Choice Washington D.C.

Image of People Registering for School

Complete the registration form below. Once your application is received, we will contact to schedule an interview. If you do not hear from us within 48 hours, please contact us 202.747.5498 to make sure your application was received.

Applicant Information

Last Name

First Name

M.I.

Gender Male Female

Race/Ethnicity

D.O.B.

Street Address

Apt/Unit

City

State Zip Code

Ward

Home Phone

Cell Phone

Current Grade Level

Current School

Have you ever attended a GED Program? Yes No

If Yes, where?

Additional Information

Do you receive Medical Assistance (Medicaid) under the DC Medical Assistance Program?
Yes No

Do you currently receive special education services at your current school? Yes No

If yes, do you have a current individualized Education Plan (I.E.P.)? Yes No

Do you have a current 504 Plan? Yes No

Select the following services you have and/or are still receiving. Select all that apply.

Speech and Language	Occupational Therapy	Physical Therapy
Counseling	Resource Room	Self Contained Classroom
Visually Impaired	Deaf and Hard of Hearing	Inclusion Services
Adaptive Physical Education

Check all statements that apply to you.

Could Use Extra Help in Reading	Is Easily Frustrated in School
Gets teased by other Students	Has a Hard Time getting along with other People
Could Use Extra Help in Math	Has Difficulty concentrating for long periods of time
Could Use Extra Help in Writing	Has a Hard time following directions

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