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PARTICIPANT INFORMATION
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Please select the program that you are registering for:
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Early Childhood (pre-K/Kindergarten)
Social Connections (Grades 1-5)
Teen Time
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No
Early Childhood (pre-K/Kindergarten)
Social Connections (Grades 1-5)
Teen Time
If you are registering for Early Childhood, please select the program timeframes that would work best for you:
Morning 9:00 am-11:30 am
Afternoon 1:00 pm-2:30 pm
Late afternoon 4:30 pm-5:30 pm
Have you already set up a consultation? If so, what date and time?
If you haven't set up a consultation, we will contact you to schedule.
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Participant First Name
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Participant Middle Name
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Participant Last Name
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Gender
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Female
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Birthday
MM
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DD
/
YYYY
Grade
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School Name and District or Homeschooled?
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Medical Diagnosis
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Educational Classification
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Does your child have an IEP?
If so, please feel free to submit a copy so that we may best understand your child.
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No
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Participant Street Address
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Participant City
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Participant State
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Participant Zip Code
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