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New Client Enrollment

Use ONE form per child

STUDENT DETAILS

First Name

Last name

Birthday

Grade

Current School Enrollment

Current Qualifying Disability or Diagnoses (if any)

If 18 or older:

Release on File

PARENT / GUARDIAN INFORMATION

Name

Relationship to Student:

Select an Address

Contact Phone Number

Other Telephone

Contact Email

Additional Information (If any)

Your Signature

Today's Date

Upload any associated documents, including any current IEP or Evaluations

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Upload File

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