PARTICIPANT INFORMATION
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Please select the program that you are registering for: *
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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:
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.
Participant First Name
Participant Middle Name
Participant Last Name
Gender
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Birthday
MM
/
DD
/
YYYY
Grade
School Name and District or Homeschooled?
Medical Diagnosis
Educational Classification
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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Participant Street Address
Participant City
Participant State
Participant Zip Code
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