Preschool Enrollment Form

1

Parent Name* This field is required.

First Name

Last Name

2

Phone* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

4

Student Name* This field is required.

First Name

Last Name

5

Student Date of Birth* This field is required.

Date

6

What Grade Level is your Student?* This field is required.

7

Do you currently have DDD Services?* This field is required.

YESNO

8

Are you familiar with the ESA Program* This field is required.

YESNO

9

Primary Diagnosis* This field is required.

(A) Autism

(MD-SSI) Multiple Disabilities & Severe Sensory Impairments

(SID) Severe Intellectual Disabilities

11

Campus I'm Interested in.* This field is required.

Maryvale

Show Low

Silver Creek

12

How did you hear about us?* This field is required.

Local Event

Family/Friend

Employee Refferal

Social Media (Facebook, Instagram, Youtube)

Google Search

Other