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Connect+ Enrollment Application 2021-22
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* Indicates required question
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
Parent Name (first and last)
*
Your answer
Parent Primary Phone Number
*
Your answer
Parent Work Phone Number
*
Your answer
Parent E-mail
*
Your answer
Mailing Address
*
Your answer
Student Name (first and last)
*
Your answer
Student's Full Birthdate
*
Your answer
Student Phone Number (if applicable)
*
Your answer
What is your student's current grade?
*
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Student MLSD E-mail (if applicable)
*
Your answer
What school district do you reside in?
*
Your answer
What school is your student currently attending or last attended?
*
Your answer
How did you hear about Connect +
*
Your answer
Does your student have a 504 Plan?
*
Yes
No
Not sure
Does or did your student have an IEP?
*
Yes
No
Do you have reliable Internet access?
*
Yes
No
Are you interested in accessing mental health/wellness services?
*
Yes
No
Maybe
Why are you interested in Connect+ ?
*
Your answer
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