INQUIRY FORM
Grade Currently in:
Tour Completed:
Website:
Name
Student First Name
Student Last Name
Person Taking Information:
DateTime
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Month
/
Day
Year
Date
Parent Name
Parent Phone #
Parent Email
example@example.com
Relationship to Student
Mother
Father
Brother
Sister
Other
Student Full Name
DOB/Age
Gender:
Male
Female
Prefer Not To Say
Diagnosis of Student
Currently in School? If so, Where?
Current Grade?
Academic level: Math
Academic level: Reading
Biking on their own?
Yes
No
Fully Toilet Trained?
Yes
No
Communication:
Verbal
Communication Device
Sign
Non-Vocal (gestures/leading/picture exchange system)
Which One:
Other
Reinforcers: What are they interested in daily?
Social Skills: What areas do they struggle with?
Social Skills: What areas are their strengths?
Behaviors: What areas do they struggle with?
Behaviors What areas are their strengths
Special Diets/Allergies
Medications
Receiving Outside Private Therapies?
N/A
PT
OT
SLT
ABA
Family Information- Lives with:
Prior School History
Why are you looking for a new school?
What are you wanting out of a school for your child?
How did you hear about us?
Payment Options:
FESUA Scholarship with Step Up for Students
Paying Monthly/Quarterly/Yearly
Pathways For Life Academy 7/2024
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