DTBA Pre-Enrollment Form
Help us better understand your child’s unique needs and strengths by completing this survey. Your responses will guide us in creating a supportive and personalized learning environment at Dare To Be Academy.  
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Email *
Child’s full legal name: *
Child's preferred name:
Your name/relation to child: *
Contact Number: *
What are your child’s strengths? *
What are your child's challenges? *
What is you child's official or suspected diagnosis? (I.e. autism, ADHD, cerebral palsy, sensory processing disorder, dyslexia, etc.) *
What are the contributing factors to your child becoming overstimulated? *

What are your child's responses to overstimulation?

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What are methods for regulation that work best for your child? *
Please describe your child’s communication abilities. *

Please describe your child's toileting abilities.

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Does your child use profanity, engage in self-harm, harm others or engage in disrobing behaviors? If yes to any, please explain. *

Are there any environments, media, or experiences your child is regularly exposed to that involve themes such as profanity, violence, mature or adult content, or alternative spiritual practices  (e.g., witchcraft, fortune telling, divination, etc.)? If yes, please explain.
This may include movies, music, games, social interactions, or family traditions. Your response helps us understand how to best support your child’s holistic development within our values-based learning environment. All information is kept confidential and used solely for enrollment consideration.

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Does your child elope? *
Does your child have ARFID or Pica? If yes to either, please explain. *

Please list any allergies your child may have.

Please list any medications your child is taking.
Please list any special dietary needs (i.e. gluten-free, dairy-free, vegan/vegetarian, etc.)
Please list your child's preferred foods (i.e. snack, meals, beverages.) *
Please list your child's preferred toys/leisure items/sensory favs (i.e. toy cars, dolls, puzzles, books, sensory swing, weighted blanket, etc.) *
Please list your child's preferred topics of interest (i.e. trains, solar system, animals, Bluey, Peppa Pig etc.) *

Please list your child’s preferred academic subjects (i.e. math, spelling, music, art, STEM, etc.)

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Please share any and all of your child's special talents, gifts or abilities.

If needed, are you able to provide a 1-on-1 for your child during school hours? (ABA, respite provider, trusted family member, etc.)

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Is there anything else you would like us to know about your child? *
How did you hear about us? *
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