Study Hall Enrollment Form

Enrollment Intake Form

This intake helps us personalize your child’s experience from day one and should take about 10 to 15 minutes to complete.
Student Name

First NameLast Name
Student Photo

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Try to find a photo that captures their personality! Cancelof
School
FIRST Day of School for current or upcoming school year:

MonthDayYear
Date
LAST Day of School for current or upcoming school year:

MonthDayYear
Date
School Calendar Link:
This is for our scheduling purposes. Please either link a calendar or upload a calendar document.
School Calendar File

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Current Grade
Date of Birth
Parent / Guardian 1 Name

First NameLast Name
Parent / Guardian 2 Name (Optional)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Contact Phone Number

Area CodePhone Number
Primary Contact Email
Secondary Email (Optional)
How would you prefer we communicate with you?

Other
For future scheduling confirmations, what is your preferred contact method?

Other
Study Hall Location

Other
How did you hear about us?
What teacher will your child be working with?
Learning strengths and areas where support is needed

Other
If applicable, who referred you?
If none, state N/A.
Food Allergies
If none, state N/A.
Is your child allergic to any pets/dogs/reptiles?
If none, state N/A.
Tell us about your child’s strengths, needs, and support history
What makes your child unique?
What are some of your child’s favorites? (Movies, color, activities, food, etc.)
Student Interest/Hobbies :
Please share any diagnoses or evaluations relevant to learning
Please include any diagnosis
If applicable, is your child aware of their diagnosis?

Other
How is your child doing in school right now?
Has your child received tutoring or support before? If yes, please share details.
What are your academic goals or hopes for your child?
What are your social or emotional goals or hopes for your child?
May we take and share photos of your child on our social media outlets?
Outdoor Learning Permission
Photo and video consent

Testing/School Documents

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Any psychological testing reports, IEPs, etc. Cancelof
Parent / Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Rows	Full Name	Address	Contact Number
1
2

Enrollment Intake Form