Student Information
Student Name
*
First Name
Last Name
Age
*
Grade Level
*
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1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Current School
What are your student's strengths, personality traits, & social abilities?
Diagnosis or Areas of Struggle
*
Please upload psychoeducational evaluations, IEP or 504 plan *strongly recommended*
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e.g. Formal Diagnosis and Evaluations from Doctors, Therapists, Teachers or IEP from previous school
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Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship
*
ex. Father, Mother, etc.
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Second Parent/Guardian Information
Name
First Name
Last Name
Relationship
ex. Father, Mother, etc.
Phone Number
Format: (000) 000-0000.
Email
example@example.com
How did you hear about Educational Pathways Academy?
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Search Engine (Google, Bing, etc.)
Facebook
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Family/Friend
EPA Parent
Current School
Tutor
Healthcare Provider (Pediatrician, Psychologist, Therapist, etc.)
Other
Campus Preference
Please Select
EPA North Campus (Grades 3rd-12th) - 23601 North Commons Drive, Bonita Springs, FL 34134
EPA South/Doris Frey Campus (Grades 1st-8th) - 1351 Pine Street, Naples, FL 34104
Does your student have any allergies or medical conditions we should be aware of?
Additional Information
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