CONFIDENTIAL IN-TAKE
Hello, if you would like information about our programs, please fill out this 2-minute in-take and someone will contact you within 24-48 hours. This information will not be given to any agency and/or persons without your permission. Thank you.
Today's date *
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How did you hear about us? *
Student/Client First name *
Student/Client Last name *
Date of birth *
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Age *
Sex *
Parent/Guardian name
Parent/Guardian Email
Parent/Guardian Phone Number
Address *
City *
If other, please name the city below.
State *
Zip code *
Grade *
Middle/High school (if attending one). *
If other, please name the elementary/middle/high school below.
Current trade school/college/university *
If other, please specify below
Email *
Phone number *
Ethnicity *
Known Language(s) *
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Do you have computer access at home? *
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