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EMCC Application Form
The Enhancing Minds Cognitive Center (EMCC) will consider any student for enrollment.  Our Admissions team will speak with parents and will ask to see a wide variety of reports, assessments, and observations in order to round out the picture of who each student is as a learner and to determine how the EMCC is the proper fit for that student.

During an initial inquiry/visit, the EMCC would like to gather as much information as possible about any prospective students and where they might need strengthening with learning.  Please complete this form for EACH prospective student.
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Email *
Student's First & Last Name *
Student's Preferred Name *
Student's Date of Birth (dd/mm/yyyy) *
Student's Gender *
Student's school/institution/profession *
Student's Grade/Year Level *
Parent/Guardian (primary) First & Last Name *
Parent/Guardian (primary) Mobile Number *
Parent/Guardian (primary) E-mail Address *
Parent/Guardian (secondary) First & Last Name *
Parent/Guardian (secondary) Mobile Number *
Parent/Guardian (secondary) E-mail Address *
Subjects/Areas to strengthen or address  include (check all that apply) *
Required
EMCC Program of Interest (10 month program) (check all that apply) *
Required
Cognitive Enhancement Options (10 months) - Assessment NOT required *
Required
Initial Enrolment Meeting Dates (When are you available to meet?)  check all that apply *
Required
Referrals (other people who you think might benefit from this program)
How did you learn about our center? *
Thank you for taking the time to compete this form.  An EMCC representative will be contacting you shortly to set up the initial enrolment meeting.   Questions/Comments?
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