Registration

Date

Interested in (please check all that apply):

Seffner CampusSouth Tampa CampusABA TherapySpeech TherapyOccupational TherapyBefore CareAfter CareSummer Camp

Student Name *

Date of Birth *

Diagnosis

Parent Name(s) *

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Primary Phone *

Secondary Phone

Parent Email

Current School

Reason for changing schools

Does your child have an IEP or a 504 Plan?

McKay Scholarship

Gardiner Scholarship Amount

Reason if dismissed from previous school

Medical Insurance Company Name

ABA Therapy Company

Speech Therapy - Hour/Week

Occupational Therapy - Hours/Week:

Please check all that apply:

My child is potty-trained.My child has a history of seizures.My child has disruptive behaviors.My child takes medicine at school.My child elopes.My child has more than just seasonal allergies.My child has pica.

If your child has a history of seizures, what is the frequency?

Date of last seizure

Please describe disruptive behaviors, if applicable.

List of current medication, if applicable.

Allergies, if applicable.

Are you willing to volunteer 15 hours per year for fundraising and or other events?

2021-2022 Registration Form

Verification