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Autism Collier Charter School Enrollment Form
Today's Date
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Month
-
Day
Year
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Student's Legal Name
*
First Name
Last Name
Student Date of Birth
*
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Month
-
Day
Year
Date Picker Icon
Place of Birth
*
Current Age of Student
*
Current Grade of Student
*
Gender
*
Please Select
Male
Female
Other
Race
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Last School Attended
*
Guardian 1 Name
*
First Name
Last Name
Guardian 2 Name
First Name
Last Name
Guardian 1 Occupation
Guardian 2 Occupation
Guardian 1 Email
*
example@example.com
Guardian 2 Email
example@example.com
Guardian 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child Lives With:
Please Select
Guardian 1
Guardian 2
Both Guardians
Other
Does the Child Have Any Allergies?
Please Select
Yes
No
If yes, List Allergies:
Does Your Child Have Seizures?
Please Select
Yes
No
Does Your Child Require Medications?
Please Select
Yes
No
If Yes, Please List Medications:
Please List Any Other Relevant Medical Information:
What Private Therapy Does Your Child Receive?
Are You Interested in Before or After School Care Programs?
Please Select
Yes
No
Maybe
Does Your Child Have a Medical Diagnosis of Autism?
*
Yes
No
Does Your Child's Individualized Education Plan (IEP) list autism spectrum disorder (ASD) as a Primary or Secondary Disability Category?
*
Yes
No
My child does not have an IEP
Does Your Child's Individualized Education Plan (IEP) list Modified Curriculum in the Accommodations/Modifications section?
*
Yes
No
I'm not sure
Upload Copy of Most Recent IEP
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Upload Copy of Most Recent Educational Evaluation
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Upload Copy of Medical Diagnosis (if applicable)
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Please Upload a copy of any other relevant documentation you would like to provide:
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Uploading Files
If you have any problems uploading documents due to file size, you can upload them to a secure folder here: https://pigeonfiles.com/u/mpmagdvneuhbnvd6cm6-q4
Do you have another child for whom you will be submitting an application?
Please Select
Yes
No
Signature
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