Alternate Parent/Guardian/Caregiver - Name, Relationship, and Number: *
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Emergency Contact - Name, Relationship, and Number (include cell and work number when relevant): *
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How did you hear about this service? *
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Student Information:
Child First Name: *
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Child Last Name: *
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Current Grade *
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Current School *
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Student Profile:
What are the reasons for wishing the applicant to enroll in EF Coaching? *
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Describe the applicant's academic areas of difficulty with executive function? (eg. planning, prioritizing, organization, time management) *
Your answer
Has the applicant received remedial instruction, such as learning assistance or tutoring, either at, or outside of his or her current school? If yes, please provide details.
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Has your child attended or applied to Fraser Academy before?
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Please select the boxes that apply as to the information you can provide us for creating your child's program: *
Please submit copies of these documents electronically to FAx or hard copies to the school (2294 West 10th Ave) to complete the registration.
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Instructional Options:
We want our lessons to be: *
Desired Start Date *
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Admissions Request *
Days for Service *
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Preferred Time *
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Medical Information:
Student's Date of Birth: *
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Please indicate any medical information or allergies (if this does not apply, please type "N/A"): *
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Parent/Guardian Consent:
I understand that photos and media (eg. photos) from After3 may be displayed throughout the school, included in our newsletters/eblasts, posted on our website, placed in online or print ads and/or used as a part of our faculty evaluations. *
Payment:
Please select one of the four payment options. *
Confirmation:
I understand that the fee for After3 Programs at Fraser Academy is non-refundable, your 6 sessions can be coordinated directly with your instructor with the coach. 24 hours notice is required to reschedule an appointment free of charge. *
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Signature (type Parent/Guardian Name): *
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