LILLY Program Enrollment Interest Form

Program Enrollment Interest Form

Please complete this form if you are interested in learning more about enrolling your child in LILLY Learning Center's academic programs.
SECTION 1 - Parent/Guardian Information

Tell us about the parent or guardian making this request.
First Name (Parent/Guardian)*
Last Name (Parent/Guardian)*
Phone (Parent/Guardian)*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (Parent/Guardian)*
example@example.com
SECTION 2 - Child Information

Tell us about your child.
What is your child's full name?*
What is your child's age?*
SECTION 3 - Program Interest

Let us know which programs or services interest you.
Hybrid Homeschool ProgramK-1 Foundations ProgramBilingual Early Learning Co-OpEnrichment ClassesKids in Biz ProgramMusic LessonsSummer CampSAT PrepTutoringOther
SECTION 4 - Contact Preferences

How can we best reach you?
8:00am - 12:00pm12:00pm - 5:00pmAfter 5:00pmWeekendsOther
PhoneTextEmail
SECTION 5 - Optional disclosures for student support (AROS)

At LILLY, we believe every child belongs here — exactly as they are. Some learners benefit from individualized accommodations or additional support to participate comfortably in a structured learning environment. This section helps us connect your family with the right people as we learn more about your child’s needs.
About Our AROS Team:

LILLY’s Adaptive Routes of Support (AROS) team is a collaborative group of educators and specialists who work alongside families to build individualized pathways for students who benefit from a little more intentionality in how they access and experience learning. A disclosure here will prompt a personal follow-up from a member of our AROS team as part of our inquiry process.
📌 Important Information for Parents/Guardians

The sectional containing the optional disclosure questions below are intended for parents with a child or children who have a known or observed need for accommodations within a learning environment — whether or not a formal diagnosis is in place. This may include physical, sensory, neurological, behavioral, communication, or emotional needs that meaningfully affect how your child accesses learning or participates in a group setting.

It is not intended for general learning preferences or program requests, though you may use the open comment/question field at the end of this form to share those details with our team.
YesNoI'm unsurePrefer not to say
Speech-Language Pathology (SLP)Occupational Therapy (OT)Applied Behavior Analysis (ABA) or Behavioral SupportPhysical TherapyChild Psychology or Mental Health CounselingSpecial Education Services and/or has received an IEP / 504 PlanOther
Tell Us About Your Child's Support Needs (OPTIONAL)

These may include, but are not limited to: Hearing differences, including Deaf or hard of hearing identity; vision or low-vision differences; sensory processing differences; physical access or mobility needs; speech, language, or communication differences — including AAC use; social communication differences; emotional regulation or co-regulation support needs; neurodevelopmental differences such as ADHD, autism, or dyslexia; learning or processing differences; behavioral support needs or patterns of dysregulation in group settings; mental health support needs; any other area where your child benefits from environmental adjustments or individualized strategies in a learning setting.
Please feel free to use the space below to share the information you are comfortable disclosing, including your child's support needs and anything else that could be helpful to share with our AROS team.
📌 Consent and Permission

Check each box to confirm that you understand and consent to the conditions outlined below.
I understand that sharing my child’s support needs here will prompt personal outreach from LILLY’s AROS team as part of our family inquiry process.I give LILLY Education Foundation’s AROS team permission to discuss my child’s individual support needs with essential members of LILLY’s teaching and operational team, solely for the purpose of evaluating how we may best support my child.I give LILLY’s AROS team permission to contact me directly to discuss my child’s needs and LILLY’s current capacity to serve them well.I understand that LILLY’s AROS team will communicate openly with our family about next steps, current capacity, and available options.The information I share here is held with care and used only in service of my child and our family’s inquiry with LILLY. 4
Signature
SECTION 6 - Additional DETAILS
Please use this area to share additional details about your child or ask our team any questions you may have.
Search engine (Google, Yahoo, etc.)Social media (Facebook, Instagram, etc.)Word of mouthAn eventOther
Yes, I'd like to receive updates and newsletters from LILLY Education Foundation
Should be Empty:

Program Enrollment Interest Form

SECTION 1 - Parent/Guardian Information

SECTION 2 - Child Information

SECTION 3 - Program Interest

SECTION 4 - Contact Preferences

SECTION 5 - Optional disclosures for student support (AROS)

About Our AROS Team:

Tell Us About Your Child's Support Needs (OPTIONAL)

📌 Consent and Permission

SECTION 6 - Additional DETAILS