Private School Enrollment
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Email *
How did you hear about ELI? *
Student's Full Name *
Student Gender Identity *
Pronouns Student Prefers *
Student's Street Address *
Student's 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 Email *
Parent/Guardian 1 Zip Code *
Parent/Guardian 2 Email *
Parent/Guardian 1 Cell Phone Number *
Parent/Guardian Work Phone 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 Phone Number *
Parent/Guardian 2 Work Phone Number *
Name, phone number & address for the main person responsible for scheduling *
Student's Date of Birth *
Student's 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 child has (please say "none" if there are none) *
Please list all suspected diagnosis's you or others suspect your child may have (please say "none" if there are none) *
Please list your student's strengths, favorites, joys, interests, activities *
Please list any other professionals and their contact information that your child has seen *
What do you hope ELI will accomplish with your child? *
What else do you want us to know about your child? *
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 info@embracelearning.org. *
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A copy of your responses will be emailed to the address you provided.
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