ENROLL

Student Intake Form

* Indicates required field

Child's Name *

First

Last

Parent's Name *

Birthday *

Gender *

Age *

Email Address *

Cell Number *

What type of educational setting does your child attend? *

Work Number *

Does your child have a medical diagnosis? *

What school does your child attend? *

if yes, please provide the doctor's name and age diagnosed *

please provide any additional information that you think may be helpful for us to service your child *

Please provide the names of any person(s) that are permitted to pick up your child: (Must present valid i.d.) *

Submit