Impact Academy: Academic Support Preregistration
Please complete one survey per student and use or create and use a GMAIL ACCOUNT when completing this form. Thank you.
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Email *
Do you have a family member or close family friend in the program? If yes please list the scholar or tutor's first name. *
Mailing Address *
Phone Number *
Parent's Name *
Scholar's Name *
Scholar's Age *
Scholar's Grade *
Current Academic Instruction Model *
Academic Strengths *
Academic Challenges *
Tell me one fun fact about your scholar *
Subject(s) requested (Check all that apply) *
A copy of your responses will be emailed to the address you provided.
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