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Student Intake Form
*
Indicates required field
Child's Name
*
First
Last
Parent's Name
*
Parent's Name
*
Birthday
*
Please provide in mm/dd/yyyy format
Gender
*
Male
Female
Age
*
Email Address
*
Cell Number
*
What type of educational setting does your child attend?
*
General Ed/Inclusion
Special Education (part of the day)
Special Education (full day)
Private School
Has a 1:1 at school
Please select all that apply
Work Number
*
Does your child have a medical diagnosis?
*
Yes
No
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
Home
VOLUNTEER
About
Community Outreach
Blog
Peer Mentors
ENROLL
EVENTS
Media / Gallery
Testimonials
DONATE
CONTACT US