Learning Pod Registration Form
Please fill in the form below.
Parent Information
Parent Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Emergency contact name
*
First Name
Last Name
Emergency Contact No.
*
In order to better assist families, AWA offers payment plans, sliding scale fees, etc. Are you in need of assistance?
*
Please Select
Yes ( personal pay only)
no
I am using step up
Student Information
Student(s) name
*
Student(s) name
Gender
*
Please Select
Male
Female
Gender
Please Select
Male
Female
current grade :
*
Please Select
7th
8th
current grade :
Please Select
KG
1st
2nd
3rd
4th
5th
6th
7th
8th
Does the student struggle to stay on task?
*
Please Select
yes
no
a little
not sure
Does the student struggle to stay on task?
Please Select
yes
no
a little
not sure
Does the student have trouble staying in his or her seat?
*
Please Select
yes
no
not sure
Does the student have trouble staying in his or her seat?
Please Select
yes
no
not sure
Please select unique learning abilities
*
Autism
ADHD
ADHD combined
not sure
none
Other
Please select unique learning abilities
Autism
ADHD
ADHD combined
not sure
none
Other
This student's reading level is..
*
Please Select
low
moderate
high
not sure
This student's reading level is..
Please Select
low
moderate
high
not sure
This student's math level is...
*
Please Select
low
moderate
high
not sure
This student's math level is...
Please Select
low
moderate
high
not sure
Please give any additional information about the student's academic needs
*
Please tell me your child/children favorite color, animal, hobbies, etc.
*
Can your child/children participate in rewards day? This is done once a month
*
Please Select
yes
no
Please list any allergies
*
Permission to call 911 and administer CPR if necessary?
*
Please Select
yes
no
Payment method
I am using...
*
Please Select
step up
personal pay
If using step up I understand service orders must be placed 2 months in advance
*
Please Select
ok
I am using private pay and want to pay the monthly tuition...
Please Select
weekly
bi weekly
monthly
Additional Information
I understand that additonal documents must be reviewed and signed in person
*
Please Select
yes
* I understand that this is a faith-based program that abides by the Bible
*
Please Select
early morning 7-9
mid- morning 9-11
early afternoon 11-2
late afternoon 2-4
late evening 5-7
Submit
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