*First Name:
*Last Name:
*Date of Birth:
    Year
    Month
    Day
*Gender: Male Female Other
Pronouns:
*Is the child fully potty trained: No Yes
Grade (if applicable): Pre-K K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
School (if applicable):
Does the child have an IEP or need 1-on-1 support for self-help skills or behaviors? No Yes
*Starting term: School Year 2023-2024 School Year 2024-2025 School Year 2025-2026
*Days attending: Monday Tuesday Wednesday Thursday Friday
Do you qualify for free/reduced lunch? No Yes
*Phone:
*Email: