APPLICATION
Students Legal Name
Students Preferred Name
Complete Address
Date of Birth
MM
/
DD
/
YYYY
Place of Birth
Current Age
Gender
Who lives in the child's household
Mothers Name
Mothers Complete Address
Home Phone
Cell Phone
Email Address
Occupation
Employer
Fathers Name
Fathers Complete Address
Home Phone
Cell Phone
Email Address
Occupation
Employer
Reason Enrollment Desired
Students Diagnosis
Diagnosing Doctor
Please list any known allergies that student has
Does student have seizures?
Does student require medication
If yes, please list medications
Please list any additional medical information
Current Educational Placement
Does student receive any other services outside of school? (OT, PT, ST, BEHAVIOR) If yes please list which services and how many hours for each
Have you, as a parent received training in applied behavior analysis?
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