Connect+ Enrollment Application 2021-22

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Email *
Today's Date *
Parent Name (first and last) *
Parent Primary Phone Number *
Parent Work Phone Number *
Parent E-mail *
Mailing Address *
Student Name (first and last) *
Student's Full Birthdate *
Student Phone Number (if applicable) *
What is your student's current grade? *
Student MLSD E-mail (if applicable) *
What school district do you reside in? *
What school is your student currently attending or last attended? *
How did you hear about Connect + *
Does your student have a 504 Plan? *
Does or did your student have an IEP? *
Do you have reliable Internet access? *
Are you interested in accessing mental health/wellness services? *
Why are you interested in Connect+ ? *
A copy of your responses will be emailed to the address you provided.
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