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Executive Function Coaching Registration
Executive Function coaching is offered remotely. In-person sessions will be determined at the end of August 2020 in accordance with the BC Ministry of Education guidelines. Sessions are offered 1 or 2 times per week at a cost of $125 per 50 minute session.
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Student Information
Student first name:
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Your answer
Student last name:
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Your answer
Student date of birth:
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Grade or post-secondary year as of September 2020:
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Your answer
Parent/guardian information (adult learners enter N/A)
Parent First Name:
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Your answer
Parent Last Name:
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Your answer
Address:
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Your answer
Phone Number:
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Your answer
Email:
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Your answer
Alternate Parent/Guardian/Caregiver - name, relationship, email and phone number:
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Your answer
Emergency Contact - name, relationship, email and phone number (cell and work):
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Your answer
How did you hear about this service?
Choose
Fraser Academy Website
Online search
Word of mouth/email
Psychologist or other medical professional
Current school
Social media
Print media
Student Profile
What reasons are you or your child applying for executive function coaching?
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Your answer
Describe learner's areas of strength:
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Your answer
Has the learner received previous remedial instruction either in school or private tutoring? If yes, please provide details.
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Your answer
Has learner attended or applied to Fraser Academy before?
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Former Fraser Academy student or alumni (main school)
Application in progress (main school)
Previous FAx After3 student (OG, EF Coaching or Math)
None of the above
Check applicable documents to assist in customizing remedial programming:
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Please submit copies of these documents electronically to FAx or hard copies to the school (2294 West 10th Ave) as soon as possible.
Report Cards from past year
Most recent IEP
Psycho-Educational Assessment
SLP or other therapeutic reports
Other progress reports
Required
Instructional Preferences:
Desired Start Date
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Admissions Request
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Semester 1 (September 14, 2020 - December 17, 2021)
Semester 2 (January 2021 - June 18, 2021)
Full Year (September 14, 2020 - June 18, 2021)
Day(s) for Service
Monday
Tuesday
Wednesday
Thursday
Preferred time (tick all that apply)
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4:00-4:50 pm
5:00-5:50 pm
6:00-6:50 pm
Daytime hours preferred (if possible)
Required
Delivery format:
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Remote learning
Face-to-face learning (contingent upon Ministry of Education guidelines)
Either remote or face-to-face learning
Medical Information
Please indicate any medical information or allergies (if this does not apply, please type "N/A"):
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Your answer
Consent:
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By checking this box, I understand that photos and visual media from EF Coaching may be displayed throughout the school, included in our newsletters/eblasts, posted on our website, or placed in online or print ads.
Required
Please select one of the two following payment options.
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I will set up automatic credit card payments via
http://fraseracademy.plastiq.com
(2.85% service fee added)
I will provide post-dated cheques for the desired term
I will pay by Interac e-transfer to the email address
accountspayable@fraseracademy.ca
(no security answer is necessary)
I will pay with online banking with BMO, HSBC, Scotiabank, or any credit union by setting Fraser Academy Association as the payee and using your first name and last initial (in upper-case letters and without space) as the account number.
Other:
I understand that the fee for After3 Programs at Fraser Academy is non-refundable, and that there will be two make-up sessions per semester for any lessons missed to be coordinated by the instructor and student.
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Yes
Required
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