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Many Layers of Me Application
Please complete the information below so that we can begin to build a program specific to your child's needs. Once complete, we will review the information and connect with you personally.
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Email Address
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Child's Full Name
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Date of Birth
MM
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DD
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YYYY
Parent/Guardian's Full Name
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Phone Number
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Address
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Address Line 2
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City
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State/Prov/Region
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Postal/Zip
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Country
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Does your child currently have an IEP or 504 Plan?
Yes - 504 Plan
Yes - IEP
Not at this time - I have requested testing
Not at this time - My child no longer qualifies, but did in the past
No, there is no need for special education services
I do not wish to provide this information
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Are there any medical concerns we should know of?
Allergies (i.e. food, pollen, animals)
Asthma or other respiratory problems
Headaches/Migraines
Chronic Conditions (i.e. heart disease, diabetes, seizures)
ADHD, ODD, or others similar
Limited Mobility (i.e. wheelchair, walker, braces)
I do not wish to provide this information
Programs of Interest
Tutoring
Counseling Services
Cooking Class
Technology Camp
Learning Lab
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