Enrollment Application

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Student
Child's First Name
Child's Last Name
Gender
Child's Birth Date MM/DD/YYYY
Parent/Guardian's First Name
Parent/Guardian's Last Name
Child's Home Street Address
Child's Home City
Child's Home State
Child's Home Zipcode
Home Phone Number
Parent or Guardian Child Resides With
Mother's Alternate Phone Number
Father's Alternate Phone Number
Email Address
I am interested in receiving the following Education Center service:
Does Your Child Have a Current Diagnosis?
If Yes, What Is/Are Your Child's Diagnosis?
Does your child have an IEP?
What grade level is indicated on IEP?
If No, Please Describe Your Child's Needs:
Has Your Child Attended School?
If Yes, What Type of Classroom, What School, What District and What Duration?
What Goals Do You Expect Helping Hands to Meet During School Year?
Therapy and school services (and service provider) my child is currently receiving: (i.e. Speech, OT, PT etc.)
Child's Strengths (what is he/she good at?):
Child's Deficits (what does he/she have difficulty with?):
Speech/Language/Communication:
Gross Motor Functioning:
Fine Motor Functioning:
Behaviors (acting out, self-injurious, preservative, etc.):
Other comments:
Funding Source We Want to Utilize:
Funding Source We Want to Utilize 2:
Funding Source We Want to Utilize 3:
Funding Source We Want to Utilize 4:
Funding Source We Want to Utilize 5:
Other Funding Source