Alternate Parent/Guardian/Caregiver - Name, Relationship, and Number: *
Your answer
Emergency Contact - Name, Relationship, and Number (include cell and work number when relevant): *
Your answer
How did you hear about this service? *
Required
Student Information
Child First Name: *
Your answer
Child Last Name: *
Your answer
Current Grade *
Your answer
Current School *
Your answer
Student Profile
What are the reasons for wishing the applicant to enroll in EF Coaching? *
Your answer
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. *
Your answer
Has your child attended or applied to Fraser Academy before? *
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) as soon as possible.
Required
Instructional Options
We want our lessons to be: *
Desired Start Date *
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Admissions Request *
Day for Service (please select two options) *
Required
Preferred Time *
Required
Medical Information
Student's Date of Birth: *
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DD
/
YYYY
Please indicate any medical information or allergies (if this does not apply, please type "N/A"): *
Your answer
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 be 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, and that there will be two make-up sessions per semester for any lessons missed, to be coordinated by your instructor with the student. 24 hours notice is required for cancellation or rescheduling. *
Required
Signature (type Parent/Guardian Name): *
Your answer
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