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Impact Academy: Academic Support Preregistration
Please complete one survey per student and use or create and use a GMAIL ACCOUNT when completing this form. Thank you.
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Email
*
Your email
Do you have a family member or close family friend in the program? If yes please list the scholar or tutor's first name.
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Your answer
Mailing Address
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Your answer
Phone Number
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Your answer
Parent's Name
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Your answer
Scholar's Name
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Your answer
Scholar's Age
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Your answer
Scholar's Grade
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Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other:
Current Academic Instruction Model
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Full-Time Distance Learning
Full-Time In-Person Instruction
Hybrid Model: (combination of both in-person and distance learning)
Academic Strengths
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Your answer
Academic Challenges
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Your answer
Tell me one fun fact about your scholar
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Your answer
Subject(s) requested (Check all that apply)
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Grades K-2: Reading & Writing
Grades K-2: Math
Grades 3-5: Reading & Writing
Grades 3-5: Math
Grades 6-8: Reading & Writing
Grades 6-8: Math
Grades 6-8: Science
Grades 9-12: English/Language Arts
Grades 9-12: Math
Grades 9-12: Science
Other:
Required
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