Prospective Families List
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What year would you like to enroll?
*
Please Select
2026-2027
2027-2028
2028-2029
2029-2030
If space becomes available mid year, would you be interested in enrolling?
*
Yes
No thank you
How did you hear about us?
*
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Student #1 Info
Student #1 First & Last Name
*
First Name
Last Name
Student #1 Grade at Enrollment
*
Please Select
K
1st
2nd
3rd
4th
5th
6th
7th
Student #1 Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student #1 Current or Previous School (or VPK)
*
Does Student #1 have any of the following? (Check all that apply)
*
Medical or health concerns (asthma, allergies, ADHD, anxiety, seizures, diabetes, vision or hearing issues, medications, etc.)
Speech or language difficulties
Occupational therapy needs (fine motor skills, handwriting, sensory processing, coordination, etc.)
Reading difficulties (including dyslexia)
Math difficulties (including dyscalcula)
Other learning, attention or developmental needs (focus/attention challenges, writing difficulties, behavioral or emotional support, autism-related needs, etc.)
None
Please describe the checked items and any supports or accommodations that help your child:
*
Would you like to add another student?
*
Yes
No
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Student #2 Info
Student #2 First & Last Name
First Name
Last Name
Student #2 Grade at Enrollment
Please Select
K
1st
2nd
3rd
4th
5th
6th
7th
Student #2 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student #2 Current or Previous School (or VPK)
Does Student #2 have any of the following? (Check all that apply)
*
Medical or health concerns (asthma, allergies, ADHD, anxiety, seizures, diabetes, vision or hearing issues, medications, etc.)
Speech or language difficulties
Occupational therapy needs (fine motor skills, handwriting, sensory processing, coordination, etc.)
Reading difficulties (including dyslexia)
Math difficulties (including dyscalcula)
Other learning, attention or developmental needs (focus/attention challenges, writing difficulties, behavioral or emotional support, autism-related needs, etc.)
None
Please describe the checked items and any supports or accommodations that help your child:
Would you like to add another student?
*
Yes
No
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Student #3 Info
Student #3 First & Last Name
First Name
Last Name
Student #3 Grade at Enrollment
Please Select
K
1st
2nd
3rd
4th
5th
6th
7th
Student #3 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student #3 Current or Previous School (or VPK)
Does Student #3 have any of the following? (Check all that apply)
*
Medical or health concerns (asthma, allergies, ADHD, anxiety, seizures, diabetes, vision or hearing issues, medications, etc.)
Speech or language difficulties
Occupational therapy needs (fine motor skills, handwriting, sensory processing, coordination, etc.)
Reading difficulties (including dyslexia)
Math difficulties (including dyscalcula)
Other learning, attention or developmental needs (focus/attention challenges, writing difficulties, behavioral or emotional support, autism-related needs, etc.)
None
Please describe the checked items and any supports or accommodations that help your child:
Would you like to add another student?
*
Yes
No
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Next
Student #4 Info
Student #4 First & Last Name
First Name
Last Name
Student #4 Grade at Enrollment
Please Select
K
1st
2nd
3rd
4th
5th
6th
7th
Student #4 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student #4 Current or Previous School (or VPK)
Does Student #4 have any of the following? (Check all that apply)
*
Medical or health concerns (asthma, allergies, ADHD, anxiety, seizures, diabetes, vision or hearing issues, medications, etc.)
Speech or language difficulties
Occupational therapy needs (fine motor skills, handwriting, sensory processing, coordination, etc.)
Reading difficulties (including dyslexia)
Math difficulties (including dyscalcula)
Other learning, attention or developmental needs (focus/attention challenges, writing difficulties, behavioral or emotional support, autism-related needs, etc.)
None
Please describe the checked items and any supports or accommodations that help your child:
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Next
Thank you for your interest in our program!
I have read and agree to Freedom Academy's Privacy Policy, and I consent to Freedom Academy collecting and using the information provided above, including information about my child, to respond to my inquiry and communicate with me about enrollment.
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