I am interested in The AuSome Program INC.

I am interested in:

The AuSome Program INC.
Interest Form

Please fill out the following form if you are interested in being contacted about one of our full time (5 day),part-time (3 day), Hybrid (combination), Homeschool Support, or other service spaces. After this form is submitted, we will contact you as soon as possible to meet your lovely family! We will discuss your child’s specific needs and vision and goals here at The AuSome Program. If you have not heard from us within two weeks, feel free to reach out at 812-917-3153.
Parent or Guardian #1 Name*

First NameLast Name
Parent or Guardian #2 Name

First NameLast Name
Child's Name*

First NameMiddle NameLast Name
Child's Birth Date*

MonthDayYear
Child's Gender*
Sibling (optional)

First NameMiddle NameLast Name
Child's Birth Date

MonthDayYear
Child's Gender
Sibling (optional)

First NameMiddle NameLast Name
Child's Birth Date

MonthDayYear
Child's Gender
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary E-mail*
example@example.com
Secondary E-mail
(optional)
Parent #1 Primary Phone Number
Parent #2 Primary Phone Number
Preferred Care Schedule*
My Exceptional Child’s Needs
Additional Comments
If not full-time, please indicate preferred schedule.
Should be Empty:

I am interested in: