Educational Intake- Nassau County
Email address *
Child's Name *
Your answer
Child's Date of Birth (MM/DD/YYYY) *
Your answer
Your Name *
Your answer
Are you the child's parent/legal guardian? *
Street Address *
Your answer
City or Town *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
School district your child resides in *
Your answer
Name of School your child attends *
Your answer
What grade is your child in? *
Primary Concern *
Does your child have a disability? If yes, please include any diagnoses *
Your answer
Does your child have a 504 Plan? *
If your child has an IEP, please let us know what the classification is *
Please briefly describe your main concerns *
Your answer
Would you prefer we contact you via email or phone? *
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This form was created inside of Long Island Advocacy Center.