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The Autism Academy of Learning

January Lottery Interest Form

Dear Parents/Guardians:

We are currently preparing to conduct a lottery drawing to determine the order of entry for all student applications received to date. To ensure the accuracy of information, we first need to verify current mailing and contact information. In addition, we need to know if you still would like your child to be considered for placement at The Autism Academy of Learning.

In order for your child to be included in this lottery, please complete this form by January 18, 2010.

Mandatory *

Student's Name *

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Parent's Name *

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CURRENT Address * Please include Street, City, State, and Zip Code

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Parent's Phone Numer *

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Alternate Phone Number

Your Email Address

By choosing yes below I am agreeing that the information provided above is accurate to the best of my knowledge. I also agree that I have the legal rights to submit this information. *

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The Autism Academy of Learning

219 Page St.

Toledo, Ohio 43620

Phone: (419) 865-7487

Fax: (419) 865-8360

info@theautismacademy.org

For specific inquiries visit the contact us page.

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