Interest Form

Are you currently:

Just exploring and considering Compass Academy

Seriously interested and considering enrollment

Ready to commit and enroll your child

Not interested at this time

Will you need tuition assistance?

Yes

No

Unsure — please send more info

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent/Guardian 1 Name

First Name

Last Name

Phone

(###)

###

####

Parent/Guardian 2 Name

First Name

Last Name

Phone

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Mobility Needs / Assistive Devices

Walker

Wheelchair

AFOs

Other

Feeding Support Needs

G-Tube

Soft Food Only

Assistance Required

None

Communication Method(s)

Verbal

AAC Device

Sign Language

Gestures / PECS

Other

I affirm that the information provided is accurate and up to date to the best of my knowledge. *

Yes

Parent/Guardian Signature *

First Name

Last Name

Date *

MM

DD

YYYY