2023 Four Factors of Wellness Program

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Please fill out this Form to APPLY for our Summer Program. This application does not guarantee acceptance into the program; we review all applicants to ensure that we are an appropriate program for your child. The information on this application is confidential.

Email *

Name of Child *

Age of Child *

Last school they attended and grade completed *

Please select the educational experience that they have completed or will be starting (check all that apply) *

General Education (no extra services)

Inclusion in General Education (with pull out services)

Behavior Focus Classroom (IMPACT)

Learning Connections Classroom

Living and Learning for Mild to Moderate IDD

Living and Learning for Severe IDD

Autism Classroom (Structured Learning)

Homebound or Modified Day

Homeschool (no connection with public/private school)

other

Required

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