Student Intake Form - The Core Program
Welcome to The Core Program,
Please complete this REQUIRED student intake form. We will use all data collected to build your profile and manage your individual academic needs. 
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Email *
Student Name *
Student Email *
Student Phone Number *
Parent Name *
Parent Phone Number *
What grade are you currently in? *
What school do you attend? *
What clubs or sports do you participate in? *
How many volunteer hours have you earned thus far?  *
What challenges are you facing in school currently? (Check All That Apply) *
How often do you study each day? *
How often do you take notes in class? *
How often do you review the notes that you have taken?  *
On a scale of 1- 10 what is your level of understanding about Executive Functioning? *
1 = Little Knowledge  5 = Very Knowledgeable
How do you prefer to learn? *
What is your learning style? *
Have you taken the SAT or ACT?  *
What were your scores?  *
What are you current grades / class scores as of today? (please list all classes and grades here) *
Use this space to share colleges, universities or programs that you are interested in visiting, attending or learning more about this year. *
How many college visits have you been on? 
In 50 words or less describe your desired goals or outcome by participating in this program.  *
A copy of your responses will be emailed to the address you provided.
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