ACCESS Literacy & Learning
HOMESCHOOL INTEREST/INTAKE FORM
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Homeschool Costs can be found on our website under "ALL READING" at shineptl.com or be sent to you upon request.  Some classes are set but we would love to know what help you are needing and for what ages and grades!  We will add to are services if there is enough interest!
Child or Children Name (s), DOB, ages *
Parents/Caregivers Names & Contact Info (Phone, Email, etc) *
Siblings Names & Ages
Address *
Child is living with *
If Other, Please indicate with whom the child resides and the legal arrangement (as far as they affect homeschooling decisions) *
List the strength(s) your child has academically or otherwise *
List the weakness(es) your child has academically or otherwise *
Please list, in detail, your child’s educational history.  How long have you been homeschooling?  How would you describe your method(s) used thus far?  Has your child ever been in public or private school or taught by someone other than at home? What grades? *
Do you have or has anyone (teacher, etc) ever expressed any concerns regarding academics? If so, please describe in detail.  Behavior?  Are there any other mitigating factors that might be considered in teaching your child?  Medication? Allergies? Medical history or current diagnoses? *
Are you a Christian believing in Jesus as your Lord and Savior? Do you attend church? If so, where? *
What is/are the reason(s) you would like your child to attend? *
*
 Do you understand that this is not a program designed to specific special needs?   *
We are more than happy to assist in those areas.  However, this is not an “intervention” and is not “therapy”.  Lesson plans are provided for the elementary group. You are responsible for grading, and keeping grades, if desired.  You are responsible for the completion, or lack thereof, of schoolwork.  Should you opt to not complete the English Language Arts and consistently not complete other portions of assignments, you will no longer be eligible for this assistance to be notified at my will. *
If there are unaddressed or unresolvable behavior issues or academic challenges beyond the scope of this offering, you will no longer be eligible for these services *
Required
Acknowledgement and Consents
By indicating below, you agree to the following:
1. Payment by the month regardless of attendance due on the first meeting of the month.
2. Purchasing of required curriculum and school supplies
3. Registering on your own to homeschool legally in the State of Louisiana
4. There are no behavior and/or special needs that you are either seeking assistance with or are aware of insomuch as it might affect the overall success of your child and the other children. Immediate removal without refund of that month’s payment will be made as the result of any behavior resulting from disrespect to classmates or Lucie B. LeDoux, or the property in which we are located at Lucie B. LeDoux’s discretion.
5. You will not take any pictures or videos on the premises at any time without my consent.
6. You agree to hold harmless Lucie B. LeDoux, Communication Station of Acadiana, LLC, Children's Therapy and Learning, LLC,  or any other locations, personal or professional. Your attendance in any way in this program is at will and you are liable for any damages or injury to person or property regardless of intent by your minor child.  You agree to be responsible for any and all legal fees that might be associated with the same.
7. You are responsible for any lunch or snacks.  Open cups and soft drinks (coke, etc) are not allowed daily.  With permission, soft drinks and other snacks are allowed per parent when field trips are made. Food will not require preparation or cooking by me and should not regularly need to be microwaved unless your child is able to operate a microwave on their own.  
8. Your child will be asked to follow rules, clean up, pray, and be kind to others.  
9. Please do not send mechanical pencils or pencil sharpeners.
10. Please do not send toys or other extra items from home.  
11. Siblings and family members, at no time, should enter not enter the therapy area (when in the clinic setting) including therapy gym or on playground equipment (when available) without permission from me.  
12. To ARRIVE ON TIME and to PICK UP on time.  You WILL be charged an additional $10 for every 15 minutes you are late.  THIS IS STRICTLY ENFORCED. I have my own family as well as own a private pediatric therapy business.  Any late fees are payable in cash and due prior to the next gathering.  Being late more than three times in any month can result in dismissal and forfeiture of your child’s spot in the group as well as the remainder of any money paid for sessions in that month.  Again, this is strictly enforced. If you are late, please have your child enter without you, quietly, and have items put away and join the group.  If you need to pick up early, please let me know that via text PRIOR to the day as you are able.  
13.  Due to my work schedule, I am unable to discuss the day’s work at drop off or pick up (see above).  Please email me at speechandreading@gmail.com with questions or concerns or to set up an appointment.  If you need to schedule a conference that will be more than 20 minutes, you will be charged for that time at my hourly therapy rate per the minutes of the conference.  I am unavailable on certain days due to family and clinic obligations.  Please note I will make every effort to get back with you as soon as possible.

Please see the next box for acknowledgement and consent.  It does not bind you to a contract for homeschool services.  If you would like to discuss any other concerns, please sign and indicate that via this form or email.


I have read, understand, and agree to all information above. *
Required
THANK YOU FOR YOUR INTEREST IN OUR HOME SCHOOL SERVICES!
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