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Future Student Application Form
Texas Autism Academy Application
We just need a few pieces of information to get the application process started.
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* Indicates required question
Full Name
*
First and last name
Your answer
What's the best
email address
for you?
*
Your answer
What's the best
phone number
for you?
*
Your answer
What's the best way to get in touch with you?
*
Phont
Email
Both
Please provide the parent/guardian's address.
*
Your answer
What's your child's name?
*
Your answer
What is your child's date of birth?
*
MM
/
DD
/
YYYY
How old is your child?
*
Your answer
Gender
*
Male
Female
Prefer not to say
Other:
Does your child currently attend school?
*
Yes
No
Other:
Please list all previous schools
*
Your answer
Please list any previous Therapy (ABA, Speech, OT, PT, Other)
*
If none apply, please write in "none".
Your answer
Does your child have a medical and/or educational diagnosis of Autism Spectrum Disorder or PDD-NOS?
*
Texas Autism Academy requires your child to have a medical and/or educational diagnosis.
Medical
Educational
None
Other:
Would you like to schedule a tour of the school?
*
Yes
No
Maybe
How did you hear about us?
*
Friend or Family Member
Doctor or Therapist
Event or Fundraiser
Social Media
Google, Yahoo, Bing Search
Other:
You are welcome to share any other information about your family or your child here.
Your answer
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