PACE Enrollment Form

PACE Enrollment Form

Prepare | Acheive | Create | Evolve
PACE takes place on Thursdays 4-5:30pm

@ The RISE Center, Vero Beach

This does not include any program outings or add-ons based on when you enroll.

Tuition for this program is $200 per month. Additional outing fee of $15 per month. We can directly bill the FES-UA scholarship for these fees.
Student Name*

First NameLast Name
DOB*

MonthDayYear
Date
Parent/Caregiver Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
High level of promptingModerate level of promptingCan complete tasks independently
What school does your child attend?*
Name of school or home school
What goals would you like to see your child achieve out of PACE? *

How did you hear about PACE?*

Rows	Select	Specify please
School
Friend/Relative
Doctor/therapist/other professional
Social Media

I understand that after starting this program it may be determined that my learner would benefit from ABA therapy in order to meet the expectations of this program. If I choose not to seek ABA therapy support, enrollment may be put on hold or terminated.
Should be Empty: