Utah Autism Academy Interested List Form

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Please complete and submit this form to be placed on our Interested List. Once submitted, your child will be considered for placement within our program when a spot is available in his or her specific age group.

This form is used for Utah Autism Academy (1875 S. Geneva Road Orem, UT) and the newly designed Utah Autism Community Center / Adult Treatment Center (also located at 1875 S. Geneva Road Orem, UT).

Child's Full Name *

Child's Date of Birth *

YYYY

Parent/Guardian Full Name *

Parent/Guardian Full Name (2)

Primary Address (Full Address) *

Primary Phone Number *

Secondary Phone Number

Primary Email *

Child's Diagnosis *

Insurance Provider *

How did you hear about our Program?

Facebook

Internet Search

Referred by my child's physican

Referred by a friend

Listed as a provider in my insurance policy

Other:

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This form was created inside of Utah Autism Academy.