Estrella Day School Interest Form

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Please fill out the information below and we will contact you to schedule a tour or provide more information about our program.

You can also contact us by phone or direct email:

EDS Director - info@estrelladayschool.org
EDS Direct Line - (480) 498-5449

Today's date:

YYYY

Student Name:

Parent/Guardian Name:

Parent/Guardian Phone Number:

Parent/Guardian Email:

What is your child's current grade level:

What school/district does your child currently attend?

What is your child's special education eligibility? This can be found on their school evaluation report or IEP.

Autism

Mild Intellectual Disability

Moderate Intellectual Disability

Severe/Profound Intellectual Disability

Specific Learning Disability

Other Health Impairment

Orthopedic Impairment

Emotional Disturbance

Speech and Language Impairment

Traumatic Brain Injury

Multiple Disabilities

Deaf/Visual Impairment

Does your child require 1:1 adult assistance throughout the school day?

Yes

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Does your child receive other therapy services in school or outside of school?

Occupational Therapy - School

Occupational Therapy - Home/Clinic

Speech Therapy - School

Speech Therapy - Home/Clinic

Physical Therapy - School

Physical Therapy - Home/Clinic

ABA or Behavioral Therapy

Other:

Does your child already have an Empowerment Scholarship? If no, would you like more information about ESA?

Yes we already have ESA

No we do not have ESA

I would like more information about ESA

Please describe any other information you would like us to know and any questions you have about our program at Estrella Day School.

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