Pre-Registration – Impact Academy

Interested in: *

Choose all that apply.

Email *

Student Name *

First

Last

Parent Name(s) *

Parent Occupation(s) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

DOB *

Diagnosis(es) *

Primary Phone *

Secondary Phone

Current School *

Dismissed from previous school(s)? *

Yes
No

Reason for Changing School/Dismissal *

Does student have: (Please check all that apply) *

IEP
504 Plan

Please upload IEP/Behavior Plan *

Click or drag files to this area to upload. You can upload up to 2 files.

Scholarship Information *

Please give the full name of the scholarship.

Date scholarship application was submitted: *

Has the scholarship been approved? *

Yes
No

Award ID? *

Please go into your EMA account to your dashboard under "My Student" to find your child's Award ID.

Scholarship Award Amount *

Please enter "unknown" if scholarship award amount has not yet been issued.

Scholarship Award Letter

Click or drag a file to this area to upload.

Matrix Score? *

Please go into your EMA account to your dashboard under "My Student" to find your child's Matrix Score.

Medical Insurance Company *

Policy Number

ABA Therapy Company *

Previously required 1/1? *

Yes
No

Is your child potty-trained? *

Yes
No

Does your child have a history of seizures? *

Yes
No

Date of last seizure, if applicable.

Does your child have pica? *

Yes
No

Is your child an elopement risk? *

Yes
No

Does your child have allergies? *

Yes
No

Allergies:

Does your child exhibit disruptive behavior? *

Yes
No

Does your child take medicine during school hours? *

Yes
No

List of current medications, if any.

Dietary Restrictions?

Additional Information?

Rich Text

Thank you for your interest in Impact Academy. We will keep your preregistration form on file. Please contact us for a school tour for the upcoming school year upon scholarship approval. If your child's funding has already been approved, you will be contacted in 24-48 hours to schedule a tour of our school.