Student Application

Parent / Guardian Address *

Parent / Guardian Phone Number *

Student's Ethnicity *

Name of School Student is Currently Attending: *

Student's Birthdate *

Other Siblings in Family *

Does the Student Have a Diagnosis of Autism? If no, Please Enter Any Pertinent Diagnoses. *

Student's Birthplace City *

Students Current Grade *

Address, City, State & Zip Code *

Last Four Digits of Student's Social Security Number *

Parent Email Address

Parent / Guardian Name *

Student's Gender *

Student's Legal Name: *

Comments

Primary Language Spoken at Home *

Parent Email Address

THE AUTISM