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Prospective Student Form
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* Indicates required question
Email
*
Your email
Parent Name
*
Your answer
Student Name
*
Your answer
Phone number
Your answer
Current School
*
Your answer
School district you reside in
*
Your answer
Current Grade Level
*
K
1
2
3
4
5
6
7
8
9
10
11
12
Required
Is your child academically on grade level?
*
Yes
No
Please list all schools/ programs your child has previously attended
*
Your answer
Does your child have any diagnoses?
*
Yes
No
If yes, please specify diagnosis:
Your answer
Does your child have an IEP?
*
Yes
No
Does your child have a behavior intervention plan (BIP)?
*
Yes
No
Please select services your child is receiving:
*
Physical Therapy
Speech Therapy
Occupational Therapy
ABA Therapy
Other
N/A
Required
How are you seeking enrollment?
*
Through private payment
Through my child's school district
I'm not sure
Are you working with an advocate and/or attorney?
*
Yes
No
If yes, please provide name and contact information for advocate and/or attorney:
Your answer
When are you interested in starting our program? (Please note that we are only accepting students for our waitlist for the 2025-2026 academic year at this time)
*
Your answer
Please provide any additional questions or comments
Your answer
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