The AuSome Program Interest Form
Let us know if you're interested in our program for students ages 12-18 (special considerations may occur upon further discussion). Let us know 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 with your family! If you have not heard from us within one week, feel free to reach out at 812-917-3153.
Student's Full Name
*
First Name
Last Name
Student's Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Current School Name/placement
*
Current Grade Level
*
Please Select
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Do you know the student's academic level?
Siblings Name (optional)
First Name
Last Name
Sibling's Date of Birth
-
Month
-
Day
Year
Date
Sibling's Gender
Please Select
Male
Female
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Preferred Option Schedule
Full Time (5 Days)
Part Time (3 Days)
Hybrid (both in person/online)
Flexible (can discuss options)
Tutoring
After-School Care (Rio Grande Bus Route)
Support Services (possible Social Skills groups, behavior therapy group, speech, OT, rec therapy, etc)
Other
Best time of day to contact you?
*
Please describe any strengths/needs or interests related to the special education program. Also list any concerns you may have. Does the child have any medical concerns?
*
Submit Interest
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