HEART Application and Support 2025-26
Student Information/Contact Information
Name
*
First Name
Last Name
Age
*
Student Diagnosis/Disability
*
Primary Guardian
*
First Name
Last Name
Primary Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Guardian E-Mail
*
example@example.com
Relationship to Child
*
Mother
Father
Guardian
Other
Secondary Contact
*
First Name
Last Name
Secondary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
*
Accommodations and Supports
How does your child best learn?
*
Touch
Visually
Orally
Other
If 'other' please describe:
How does your child best communicate with others?
*
Is a visual schedule helpful for your child?
Yes - pictures and words
Yes - pictures only
Yes - words only
No
Does your child use any special communication devices or equipment?
*
Yes
No
If yes, please describe:
Please check any of the following that may be a challenge for your child:
*
Working with others
Sharing
Expressing emotions
Strong emotional attachments
Stubborness
Non-compliance
Overly affectionate
Crying
Anger/Temper tantrums
Hitting self or others
Frustration
Disappointment
Jealousy
Coordination
Tires easily
Bathroom routines
Loud Noises
Other
Please describe supports, interventions, and/or accommodations that work best for your child.
*
Does your child have mobility issues?
*
Yes
No
If yes, please describe:
What are your child's strengths and talents?
*
What teaching strategies/techniques are most helpful when working with your child?
*
What supports help your child during transitions?
*
Do you have any safety concerns for your child?
*
Yes
No
If yes, please describe:
Do you have any goals for your student throughout their rehearsal/class process? (ex: confidence, making new friends, etc.)
What class does your child plan to enroll in this trimester/semester? If none, please state "None."
*
What production does your child plan to audition for this trimester? If none, please state "None."
*
Any additional information you would like to share about your child:
I acknowledge that students enrolled in the HEART program are provided supervision and supports in small and large group settings, First Act does not provide one-on-one supports or supervision.
*
Yes
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