Boost Program Student Application Form Initial

Boost Program Student Application
Student Name*

First NameLast Name
Parent Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How old is your student?*
What type of education program is your student enrolled in? i.e. public, private, homeschool.*
Please include name of school
What challenges does your student have with accessing extracurricular activities?*
What supports are essential to have in place for supporting your student?*
What do you want the Boost Program to do for your student? *
What Semester Are You Applying for?*

Fall 2024Winter/spring 2025Either one is great
Please upload details of your students most recent IEP and/or behavioral plan. If homeschooled, please provide a written document addressing the most recent goals you have established for your student. *

Cancelof
Commitments to Consider Before Applying:

Families/Caretakers must commit to one semester (6 sessions) and plan to have their student attend all 6 sessions.

Families/Caretakers must complete surveys and follow up with school or therapists on completing surveys.

Families/Caretakers must complete all required counseling documentation and interviews.

Families/Caretakes will work with the team to provide interests of their student and goals for student.

By signing below I understand that I would be responsible for following up with teachers, counselors and therapists for my student during their enrollment.
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