UMHB CTP General Inquiry Form

1

Full Name* This field is required.

First Name

Last Name

2

Relationship to Child* This field is required.

3

Phone Number* This field is required.

Area Code

Phone Number

4

Email* This field is required.Please verify your email

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

5

Preferred Method of Communication* This field is required.

Phone

Email

Text Message

6

Child's Full Name* This field is required.

First Name

Last Name

7

Date of Birth* This field is required.

Date

8

Age* This field is required.

9

Type of Disability (if known)* This field is required.

10

Current School/Program (optional)

11

Does your child currently receive any accommodations or services?* This field is required.

YESNO

12

Please briefly describe:* This field is required.

13

Reason for interest in the UMHB Marek-Smith Center for Teacher Preparation:* This field is required.

14

Are there specific goals or developmental areas you hope to address?* This field is required.

15

Preferred session times or availability (if known):

Monday, 3:30-4:15 pm

Monday, 4:30-5:15 pm

Tuesday, 3:30-4:15 pm

Tuesday, 4:30-5:15 pm

Thursday, 3:30-4:15 pm

Thursday, 4:30-5:15 pm

16

I understand that this form is a general inquiry and does not guarantee placement or services.* This field is required.

17

I consent to the UMHB staff contacting me regarding this inquiry to discuss next steps.* This field is required.

18

I understand that official documentation of my child's disability will be required if we proceed with formal accommodations or enrollment.* This field is required.

19

Please type your full name as your electronic signature.* This field is required.

Full Name

20

Today's Date* This field is required.

Date