DSAV WINTER 2020 Social Program Registration
JAN. 16, 30, FEB 13, 27
Email address *
*
Student Name *
Your answer
Date of Birth (month/date/year) *
Your answer
Parent/Guardian Name(s) *
Your answer
Street Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Home Phone Number
Your answer
Mother's Cell Phone *
Your answer
Father's Cell Phone *
Your answer
Text? (yes or no) *
Mother's email *
Your answer
Father's email *
Your answer
Grade last completed *
Your answer
School District *
Your answer
Is your student on an IEP? *
Date of Most Recent ETR *
MM
/
DD
/
YYYY
Which Related Services does your child receive at school? *
Required
Primary Care Physician Name *
Your answer
Other doctors your child visits on a regular basis *
Your answer
Medical Diagnosis (List all that apply) *
Your answer
Please list any and all therapies or programs your child has been enrolled *
Your answer
Please describe your biggest concerns about your child: *
Your answer
Describe your child as a person as well as their likes and motivators: *
Your answer
MY INITIALS BELOW INDICATE THAT I AM AWARE OF THE COST OF PROGRAMMING AND WHEN FEES ARE DUE TO DSAV.
Your answer
A copy of your responses will be emailed to the address you provided.
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