ADMISSION INFORMATION

More information will be required for admission. After your form is submitted we will contact you with a request for further detailed information about your student.

Please send the following via email:

IEP or 504

most recent report card with conduct

psychological report (dated within the last 3 years)

Student Name

First Name

Last Name

Student Date of Birth

YYYY

Current School

Current Grade Level

Parent or Legal Guardian(s) Name

Best Contact Number

(###)

###

####

Email Address

Does the student have a current 504 or IEP?

If the student is currently at a private school, does he/she have a Private School Service Plan?

What is the student Diagnosed with? Please check all that apply.

ADHD

Anxiety

Dyslexia

Hyperlexia

Dysgraphia

Dyscalculia

Auditory Processing Differences

Other

Does the student have any significant medical history or allergies?

Current Medications

What is the student currently struggling with?

Today's Date

YYYY

Parent Signature

By typing your name here you acknowledge this as an electronic signature.