NPA Enrollment
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Email *
How did you hear about ELI? *
Attorney representing family (if there is none please write 'none')
Student's full name *
Student Gender Identity *
pronouns student prefers *
Students' street address *
Student city *
Student State *
Student zip code *
Student's phone number *
Parent/guardian 1 name *
Parent/guardian 1 street address *
Parent/guardian 1 city *
Parent/guardian 1 state *
Parent/guardian 1 zip code *
Parent/guardian 1 email *
Parent/guardian 2 email *
Parent/guardian 1 phone number *
parent/guardian work number *
Parent/guardian 2 name *
Parent/Guardian 2 Street Address *
Parent/guardian 2 city *
Parent/guardian 2 state *
Parent/Guardian 2 Zip Code *
Parent/guardian 2 Cell number *
Parent/Guardian 2 Work Phone Number *
Name, Phone number, and address for the main person responsible for scheduling *
Students date of birth *
Students current school *
Student's Current Grade Level *
Is your child currently attending school regularly? *
Student's Teacher/Counselor Name *
please list all confirmed diagnosis's your student has (please say 'none' if there are none) *
Please list all suspected diagnosis's you or others suspect your student has (please say 'none' if there are none) *
Please list some of your students strengths, favorites, joys, interest & activities *
Please list any other professionals and their contact information that your student has seen
What do you hope ELI will accomplish with your child? *
Does your child have any allergies? *
What else do you want us to know about your student?  *
I understand that I am disclosing private, confidential information about my child to Embrace Learning Institute, LLC and give my permission to ELI to share this with employees, agents and contractors who will serve my student as needed to provide comprehensive history, background and care.  I understand I can revoke this permission at any time by sending an email to *
A copy of your responses will be emailed to the address you provided.
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