HOMESCHOOL CONNECTIONS
PRE-REGISTRATION FORM 2024-2025
Name of your child
*
First Name
Last Name
Birth date of your child
*
-
Month
-
Day
Year
Date
Name of your pediatrician
Your name
*
First Name
Last Name
Your occupation
Other parent's name
First Name
Last Name
Other parent's occupation
Does your child have special needs?
*
YES
NO
What are your child's strengths?
*
What are your child learning needs?
What are your hopes and dreams for your child?
*
Does your child have siblings?
*
YES
NO
If you answered YES, how old are the siblings?
What languages are spoken at home?
*
What holidays or traditions are celebrated at home?
Was your child formerly:
*
in a public school
in a private school
homeschooling
other
Are you familiar with the process of homeschooling?
*
YES
NO
What do you expect from homeschooling?
What program are you interested in?
*
Core Program
Enrichment Program
After-School Program
I don't know
Is there anything else you would like to share with us?
E-mail
*
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
Please Select
Friend / Family
Press
Pediatrician
Search Engine (Google, Bing)
Other
Please Specify
Submit
Should be Empty: