Student Name *

Date of Birth *

Student Grade in 2024-2025 *

Primary Parent Contact Name *

Primary Parent Contact Email *

Primary Parent Contact Emergency Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

School Student Attends *

Who besides the primary parent is authorized to pick up this student?

Allergies

Medical Conditions

Learning Challenges that impact classroom behavior and/or performance

Medications

Note: We will not be able to administer medication during sessions

Anything else that we need to know about this student?

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