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Foundations Program Interest Form
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* Indicates required question
Email
*
Your email
Parent Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Student Name
*
Your answer
Student Birth Date
*
MM
/
DD
/
YYYY
*
Male
Female
Current Grade
*
Your answer
Current School
*
Your answer
Desired date of transfer to Foundations
*
Your answer
Has student been identified as having:
*
Below Average IQ
Average IQ
Above Average IQ
I am not sure about my child's IQ
Does student have an identified learning disability or learning difficulty?
*
Yes
No
If yes, please describe
Your answer
Does student have an Autism or Asperger's diagnosis?
*
Yes
No
If yes, please describe
Your answer
Does student have an identified behavior disorder, such as Oppositional Defiance Disorder?
*
Yes
No
If yes, please describe
Your answer
Other information you would like us to know about your child
Your answer
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