Youth Learner Wait List

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* 1. Parent/Guardian Contact Information

Name

Address

Address 2

City/Town

State

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Student Name

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* 3. Student's Birthdate

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* 4. Student's Grade

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* 5. School Name

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* 6. Is your child receiving Special Education services?

Yes

No

Other (please specify)

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* 7. Please share any information about your child that you would like to share with our staff.