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THE AUTISM
ACADEMY OF
LEARNING
Parent Email Address
Last Four Digits of Student's Social Security Number
*
Parent Email Address
Comments
Other Siblings in Family
*
Does the Student Have a Diagnosis of Autism? If no, Please Enter Any Pertinent Diagnoses.
*
Parent / Guardian Name
*
Parent / Guardian Address
*
Parent / Guardian Phone Number
*
Primary Language Spoken at Home
*
Student's Birthplace City
*
Student's Gender
*
Select from the drop-down menu
Female
Male
Student's Ethnicity
*
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Black, Non-Hispanic
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Pacific Islander
White, Non-Hispanic
Students Current Grade
*
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KG - Kindergarten
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Name of School Student is Currently Attending:
*
Student's Legal Name:
*
Address, City, State & Zip Code
*
Student's Birthdate
*
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