Aba Healing Academy Registration
Thank you for choosing Aba Healing Academy. Remember, there is a $50 Application, and $100 Deposit fee. Your fee can be paid electronically through Paypal, Money Order, or Cash. (Sorry, we do not accept checks.) Both fees MUST be paid to secure your spot. 
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Email *
Child's Name (First and Last) *
Child's Birth Date *
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Child's Social Security Number *
Address *
Child's Grade (Upcoming School Year) *
Child's Ethnicity *
Child's Primary Language *
Child's Gender *
Is this child covered by a court ordered custody agreement? *
If the above answer is "YES", please list the name of the primary legal guardian of the child. *
Mother's/Guardian's Name *
Mother's/Guardian's Cell Phone Number *
Mother's/Guardian's E-mail *
Mother's/Guardian's Address *
Father's/Guardian's Name *
Father's/Guardian's Cell Phone Number *
Father's/Guardian's E-mail *
Father's/Guardian's Address *
Preferred Method of Communication *
Are there any security/custody issues with this child? *
If you answered "YES" to the question above, please help us to know the security/custody issues for the safety of your child. *
Does the child have any special needs (ADD, Asperger’s, Dyslexia, etc.) *
Are there any concerns about your child's learning abilities? *
Does your child have any allergies? (peanuts, chocolate, etc.) *
If you answered "YES" to the question above, please list your child's allergies. *
Emergency Contact #1 (First and Last Name) *
Phone Number *
Emergency Contact #2 (First and Last Name) *
Phone Number *
Child's Pediatrician *
Pediatrician's Phone Number *
In addition to those listed above (Guardian, Parents, & Emergency Contacts), please list the individuals who are also allowed to pick up your child from Aba Healing Academy. List Name's & Phone Numbers* *
Please list any individual who is NOT allowed to pick up your child from Aba Healing Academy *
My child's source of transportation will be *
Aba Healing Academy may, from time to time, document the activities of the students with photos or videos. I hereby assign and grant to Aba Healing Academy , its subsidiaries and successors, and assign the unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes *
Please acknowledge below that copies of the following documents will need to be submitted in order to complete the application process                                                            Birth Certificate, Social Security Card, Shot Records, Proof of Residency, Proof of Income, Insurance Card, Court Documents (If Applicable)                                            If additional documents are required, you will be notified by a school official. *
Please acknowledge below that completion of the application process does not guarantee admission.     *
Please acknowledge below that once admission is approved, the child's legal guardian must accept terms of admission in order for the applicant to be enrolled. *
Please acknowledge below that falsification of any information or document required will result in revocation of student enrollment. *
Choose a desired language that you would prefer your child learn. *
How did you hear about Aba Healing Academy *
A copy of your responses will be emailed to the address you provided.
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