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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 *
DOB *
MM
/
DD
/
YYYY
Gender: *
Home Address *
Phone Number *
Family Information
(Fill-in N/A if "not applicable".)
Parent/Guardian #1 *
Parent/Guardian #1 Phone
Parent/Guardian #1 E-mail: *
Parent/Guardian #2
Parent/Guardian #2 Phone
Parent/Guardian #2 E-mail
Preferred person to contact: *
Primary language spoken at home *
Other languages spoken at home:
Educational information
(Fill-in N/A if "not applicable".)
Has your child attended a preschool, kindergarten or daycare program before? *
If yes, list provider/school name *
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, please list diagnoses or difficulties *
Please list how we can can support your child with these needs (special cup, 1:1 supervision, etc.) *
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): *
Please, list any questions you may have:
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