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Catalyst Academy Pre-Enrollment Form
Please complete the following form to allow us to contact you- to answer any questions you may have, and/or to arrange for full enrollment of your child. For immediate questions, please do not hesitate to contact Brigitte Ferguson by phone at 801-200-1444 or via e-mail to Brigitte.Catalyst@gmail.com.

Catalyst Academy does not discriminate against students on the basis of sex, race, color, religion, national origin, ancestry, creed, marital or parental status, sexual orientation, or physical, mental, emotional, or learning disabilities or handicap in education programs. We do however carefully evaluate the special needs of every individual student before and during enrollment, and may recommend different providers or school settings, if Catalyst Academy is unable to meet a student's individual needs. Your child's well-being and success is our first and foremost concern. Please do not hesitate to contact us, should you have any concerns or questions about this policy.

Email address *
Student Information
(All answers in this section are required.)
Name (First and Last): *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Gender: *
Address (Street, City, State, Zip): *
Your answer
Phone: *
Your answer
Family Information
(Fill-in N/A if "not applicable".)
Parent/Guardian #1 Name: *
Your answer
Parent/Guardian #1 Phone (if different than above):
Your answer
Parent/Guardian #1 E-mail: *
Your answer
Parent/Guardian #2 Name:
Your answer
Parent/Guardian #2 Phone (if different than above):
Your answer
Parent/Guardian #2 E-mail:
Your answer
Preferred person to contact: *
Primary language spoken at home: *
Your answer
Other languages spoken at home:
Your answer
Educational information
(Fill-in N/A if "not applicable".)
Has your child attended a preschool, kindergarten or daycare program before? *
Previous School/Provider Name(s): *
Your answer
List reasons for leaving that school/provider: *
Special Needs Information
(Fill-in N/A if "not applicable".)
Does your child have special needs? *
If yes, name diagnosis or concerns: *
Your answer
Please, give brief instructions for the care for above mentioned concerns/conditions (i. e. wheel chair accessibility, communication device, diapering station, medications, 1:1 supervision etc.) *
Your answer
Does your child have or qualify for an IFSP or IEP? *
Does your child receive other therapies or services? (Check all that apply.) *
Required
Has your child received ABA services before? *
If yes, please name the previous ABA provider(s): *
Your answer
Please, list any questions you may have:
Your answer
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