APPLICATION
Students Legal Name
Your answer
Students Preferred Name
Your answer
Complete Address
Your answer
Date of Birth
MM
/
DD
/
YYYY
Place of Birth
Your answer
Current Age
Your answer
Gender
Who lives in the child's household
Your answer
Mothers Name
Your answer
Mothers Complete Address
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email Address
Your answer
Occupation
Your answer
Employer
Your answer
Fathers Name
Your answer
Fathers Complete Address
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email Address
Your answer
Occupation
Your answer
Employer
Your answer
Reason Enrollment Desired
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Students Diagnosis
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Diagnosing Doctor
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Please list any known allergies that student has
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Does student have seizures?
Does student require medication
If yes, please list medications
Your answer
Please list any additional medical information
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Current Educational Placement
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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
Your answer
Have you, as a parent received training in applied behavior analysis?
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