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New Student Interest Form
Please complete the form below and a member of the staff will contact you to set up an appointment or answer any additional questions.
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* Indicates required question
Parent or Guardian Name
*
Your answer
Student Name(s)
*
Your answer
Student's Date of Birth
*
Your answer
Phone number
Your answer
Email
*
Your answer
County of Residence:
*
Your answer
Home School
*
Your answer
Student Grade Brand
*
Elementary School (K - 5th Grade)
Middle School (6th - 8th Grades)
High School (9th -12th Grades)
Intervention Needs
*
Reading
Math
Reading and Math
Behavior Intervention
Post Secondary Planning
Credit Recovery (High School Only)
Please select whichever applies:
*
Individualized Education Plan
MTSS Tier
Section 504 Plan
Suspended or Expelled
Justice Referred
DFCS Referred
Other
Required
Referral Source
*
Social Media (Instagram, Facebook, etc)..
Chapel Hill News
Search Engine (Google, Firefox, etc.)
School/Agency Referral
Website
I would like a call to set up a time to come in to tour the center.
*
Yes
No
Feel free to use this space to share pertinent information or send questions.
Your answer
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