Registration Form
General Information
Client Name
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Ethnicity
Please Select
Prefer Not To Answer
African American
Hispanic/ Latino
Asian
Caucasian
Native American/ Alaskan
Hawaiian/ Pacific Islander
Middle Eastern
Other
Gender
Please Select
Prefer Not To Answer
Female
Male
Gender Neutral
Other
Entry Year
Grade
Semester
Please Select
Fall
Spring
Summer
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Residence Information
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/ Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Next
Emergency Contact Information
Primary Emergency | Contact Name
First Name
Last Name
Primary Emergency | Phone Number
Please enter a valid phone number.
Primary Emergency | What is client's relationship with this person?
Secondary Emergency | Contact Name
First Name
Last Name
Secondary Emergency | Phone Number
Please enter a valid phone number.
Secondary Emergency | What is client's relationship with this person?
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Next
Medical Information
Physician Name
First Name
Last Name
Physician Primary Phone Number
Please enter a valid phone number.
Physician Secondary Phone Number
Please enter a valid phone number.
Preferred Emergency Hospital Name
Please list any of the followings: current medications, medication allergies, food allergies, or chronic health concerns.
School Information
School Name
City
State
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
MH
Notes
Available Options (please choose one) If absolutely necessary, sessions will be virtual, and you will be notified in advance. Otherwise, all sessions will be in-person at GLS Little Rock.
*
Friday 4pm
Monday 5:30pm
Submission of this form indicates agreement to Student Success Strategies services. Length of service is one semester or 18 weeks (if services begin after start of semester). Cost of service is $35/session). You understand that although no deposit is required, you are responsible for monthly payment by the 5th upon the recepit of your invoice. If payment is not received by the 5th of each month the responsible party agrees to monthly draft from accoun (unless otherwise arranged with GLS in writing).
*
I agree
Signature
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