ExcelPrep Initial Inquiry Form

Initial Inquiry Form

Please complete the following form to apply for potential enrollment at Excel Prep. Once you have submitted the form, our team will evaluate your application and reach out with information on next steps.
Name of person completing application

First NameMiddle NameLast NameSuffix
Phone number of person completing application
Email of person completing application
Relationship to learner
Location
How soon are you looking to enroll this learner?
Learner Information

Please complete this section
Learner Name

First NameMiddle NameLast NameSuffix
Learner's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender
Learner Current Grade
Learner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Referral Type
Referral Type
Reason for Referral
Reason for referral, please select all that apply:
Physician Name
Primary Language
Type of programming currently receiving:
Name of current school district
Name of current school
What brings you to our program, and what are you hoping to find for your child?
Please tell us about your child's current needs, areas of strength, and any challenges or concerns that led you to seek a new school placement. You may include information about academics, communication, social skills, behavior, daily living skills, independence, or any other areas you feel are important.
Guardian Contact Information
Primary Guardian Name

First NameMiddle NameLast NameSuffix
Primary Guardian Phone Number
Primary Guardian Email
example@example.com
Primary Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Learner's Medical History
Primary Diagnosis
Secondary Diagnosis (if applicable)
Has the child ever been hospitalized due to behavioral or emotional reasons?
Please list out any other important medical concerns we should be aware of:
File Upload

Please upload the following files for review if they are available.
Upload IEP (if applicable)

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Upload Evaluation to Support Diagnosis. This would be a diagnostic report.

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Should be Empty:

Initial Inquiry Form

Learner Information

Referral Type

Reason for Referral

What brings you to our program, and what are you hoping to find for your child?

Guardian Contact Information

Learner's Medical History

File Upload