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Educational Intake- Nassau
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* Indicates required question
Email
*
Your email
Child's Name (First and Last)
*
Your answer
Child's Date of Birth (MM/DD/YYYY)
*
Your answer
Your Name
*
Your answer
Are you the child's parent/legal guardian?
*
Yes
No
Street Address
*
Your answer
City or Town
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
School district your child resides in
*
Your answer
Name of School your child attends
*
Your answer
What grade is your child in?
*
Choose
Pre-School
K
1
2
3
4
5
6
7
8
9
10
11
12
Ungraded
Primary Concern
*
Academic
Behavior
Discipline/Suspensions
Eligibility for Services
Homelessness
Placement
Residency
School Refusal/Truancy
Social or Emotional
Bullying
OPWDD Eligibility/Benefits Advisement
Required
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