ESA Information & Authorization
For families using Arizona ESA funds, please complete the information below. This allows us to properly document services and provide receipts for reimbursement. All sessions must follow studio policies and ESA guidelines.
Student Name
*
First Name
Last Name
Parent/Guardian Name
*
First Name
Last Name
ESA Student ID Number
*
Parent Email
*
example@example.com
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
With this signature, I certify I am using ESA funds for approved services. I understand sessions must be used within thesame month and missed or unused sessions may not be reimbursed. I confirm my information isaccurate and agree to these terms.
*
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