The Autism Academy of Learning

Last 4 digits of Student's Social Security Number

Student's Birthplace City  *

Student's Address  *

Student's Gender  *  Male   Female 

Student's Date of Birth  *

Student's Current Grade  *

Student's Ethnic Description  * 1 : : A-PI Asian of Pacific Islander  1 : : B-NH Black, Non-Hispanic  1 : : His Hispanic  1 : : American Indian or Alaskan Native American Indian or Alaskan Native  1 : : Multi-Racial Multi-Racial  1 : : White, Non-Hispanic (Including Middle East) White, Non-Hispanic (Including Middle East) 

Primary Language spoken at home  *

Does the student have kindergarten experience?  *  Yes   No 

If "Yes", where?

Name of school the student is currently attending?  *

School District of Residence  *

Father/Step-Father/Guardian's Name  *

Father/Step-Father/Guardian's Address  *

Father/Step-Father/Guardian's Phone Number  *

Mother/Step-Mother/Guardian's Name  *

Mother/Step-Mother/Guardian's Address  *

Mother/Step-Mother/Guardian's Phone Number  *

Other Siblings in the family

Does the student have a diagnosis of Autism?  *  Yes   No 

If no, please list any other medical diagnosis.

Your Email Address

Statement of Agreement  *  I agree that the above information is accurate to the best of my knowledge and that I have the legal right to submit this information about the above named student.