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Student Name *

Gender *
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Student Age *

Country *

City *

Please Select The Program(s) You Are Interested In: *
Elementary (Primary School)Middle And High SchoolSAT TutoringVirtual Programs

How Did You Hear About Our Academy? *
Internet SearchFriend/familyCurrent Student/parent Of SchoolEmail or Social Media AdvertisementOther

Has the child (Check all that apply): *
Been evaluated or referred for a Special Needs ProgramBeen or currently in a Special Needs ProgramRequire any type of Additional NeedNone of the Above

Indicate your interest in the SEA Exam (Check all that apply): *
I definitely require my child to sit the SEA examNot Interested in the SEAUnsure if SEA is best for my childSEA does not apply to my child

Are you completing this form on behalf of your child? *
YesNo

Is your child currently registered in a school? *
YesNo

Name Of The Last School Attended Or Current School *

Parent Name *

Parent Email *

Parent Phone Number *