Unique Abilities Program at Peace Christian Academy Questionnaire 
Please fill out this form if your family intends to enroll a student with unique abilities at Peace Christian Academy. Honesty is required as we decide if this will be a mutually beneficial partnership. Thank you!
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Email *
Full name and age of your child:
What age was your child diagnosed? *
My child was diagnosed with: *
Has your child attended school before? *
If yes, which is the last school your child attended?
What are your child’s sensory triggers? Ex: Loud noises will cause frustration and breakdowns.  *
What are your academic goals for your child? *
What are your social goals for your child? *
What are your independence goals for your child? *
What are your childs strengths? *
What are current challenges for your child? (Socially, academically, independently) *
How does your child handle transitions? *
Does your child have an RBT? *
What are short-term goals for your child? *
What are long-term goals for your child? *
Insurance Company: *
Interested in the following therapies: *
Required
I will only be paying for my child to attend aftercare and no special interest activities. *
I would like the following special interest development programs as options for my child: *
Required
I am not interested in my child learning the following subjects: *
I would like homework as reinforcement: *
Are you available to fulfill your parent volunteer hours? *
My child has the following allergies: *
My child takes the following medications: *
I have read the brochure and am aware of the fees required of my family. *
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