Academic Enrichment Application
August 2026-May 2027, M-F 10am-3pm. *Follows HCPS Calendar*
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's grade for the 2026-27 school year
*
Child's Diagnosis (if none, please type NA)
*
Child's medical conditions or allergies (if none, please type NA)
*
Parent's Full Name
*
First Name
Last Name
Parent's Email Address
*
example@example.com
Parent's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your child currently receive ABA Services?
*
Yes, with 123 ABA
Yes, with another company
No
Are you interested in 1:1 ABA services before/after Enrichment?
*
Yes, Before
Yes, After
Yes, Before and After
No
Please share why you are interested in this program :)
*
I understand that in order to be accepted, a Behavioral Assessment is required. I understand that the cost of the Behavioral Assessment is $350 and can be paid via Step Up or self-pay. I understand that the cost of the Academic Enrichment Program is $1500/month (August 2026-May 2027) and can be paid via Step Up or self-pay. I agree to 123 ABA Services, LLC's rules and policies.
*
Apply
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