Taylor Success Learning Registration for 2025-2026

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Learner's First Name

Learner's Last Name

Learner's Date of Birth

YYYY

Parent's First Name

Parent's Last Name

Parent's Phone Number

Parent's email address

Preferred Contact Method

Phone

Text

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Does your child have any diagnosed learning differences or needs?

Speech delay

Autism Spectrum

IEP or 504 Plan

ADHD/ADD

No known differences

Option 6

Other (please describe)

Yes

Maybe

Other:

Learner's Present School Name and Address

Does the Learner Have any Disabilities /504 Plan / or an IEP

Does the Learner Have Any Allergies (Please note we can not administer epi pens or medications at this time)

Submit

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