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General Information Form Florida
Moshe Gotfryd
2022-06-13T05:55:45-04:00
General Information Form Florida
Step
1
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3
33%
Primary Email Address - (This is the email address we will use for all Maxi Mind communications.)
*
This email address should match the primary email on all your Maxi Mind forms
Parent's Information
Mother's Name
*
First
Last
Mother's Email
Father's Name
*
First
Last
Father's Email
Home Number
*
Mother's Cell
*
Father's Cell
*
Address
*
Street Address
Address Line 2
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About the Child
Child's Name
*
Given Name
Last
Child's Date of Birth
*
Month
Day
Year
Grade (entering)
*
Please Select One
Kindergarten
JK
SK
Pre 1A
1
2
3
4
5
6
7
8
9
10
11
12
Other
Not Applicable
Please tell us about your child.
The more information you provide, the more we will be able to tell you if and how our program can help your child.
Medical Conditions
*
Disorders Affecting Learning
*
ADHD
ASD
Dyslexia
Other
Check all that apply
other
Describe any difficulties your child may be having at school.
*
Describe any difficulties your child is having at home or socially.
*
What are your hopes and expectations from the Maxi Mind program?
*
Additional notes or comments
*
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