INTAKE FORM
This form provides us with basic information about your family needs. Please answer all questions to the best of your knowledge.
PARENT INFORMATION
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
When do you desire to begin?
*
STUDENT INFORMATION
*
First Name
Last Name
Age
*
What grade level are you registering this child for?
*
Preschool (2 years old)
K3 (3 year olds)
K4 (4 year olds)
K5 (5 year olds)
Grade 1
Grade2
Grade 3
Grade 4
Grade 5
Grade 6
Additional Child
Please complete this section ONLY if you are interested in placement for more than 1 child.
First Name
Last Name
Age
What grade level are you registering this child for?
Preschool (2 years old)
K3
K4
K5
Grade 1
Grade2
Grade 3
Grade 4
Grade 5
Grade 6
SUPPORTING INFORMATION
Has your child ever been diagnosed with a special need? (academic or otherwise)
*
Yes
No
Has your child ever been referred for a psychoeducational assessment (learning evaluation)?
*
Yes
No
Do you have a report from a learning evaluation?
*
Yes
No
Do you have any particular need/expectation or accommodation that you would hope we can provide?
Submit
Should be Empty: