Grade or post-secondary year as of September 2020: *
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Parent/guardian information (adult learners enter N/A)
Parent First Name: *
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Parent Last Name: *
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Address: *
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Phone Number: *
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Email: *
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Alternate Parent/Guardian/Caregiver - name, relationship, email and phone number: *
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Emergency Contact - name, relationship, email and phone number (cell and work): *
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How did you hear about this service?
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Fraser Academy Website
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Student Profile
What reasons are you or your child applying for executive function coaching? *
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Describe learner's areas of strength: *
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Has the learner received previous remedial instruction either in school or private tutoring? If yes, please provide details. *
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Has learner attended or applied to Fraser Academy before? *
Check applicable documents to assist in customizing remedial programming: *
Please submit copies of these documents electronically to FAx or hard copies to the school (2294 West 10th Ave) as soon as possible.
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Instructional Preferences:
Desired Start Date *
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Admissions Request *
Day(s) for Service
Preferred time (tick all that apply) *
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Delivery format: *
Medical Information
Please indicate any medical information or allergies (if this does not apply, please type "N/A"): *
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Consent:
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Please select one of the two following payment options. *
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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