Registration

404.618.3132 office

www.stridesofexcellence.com

Circle Service of Interest

Educational Advocacy                                           Customized Tutoring                                    Home Behavior Management Intervention

Print Rich Infused Home                                       Educational Planning                                    *Diagnostic Educational Assessments

*Information in this document is protected by HIPAA privacy laws and should be handled accordingly.

Application

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Home Address

Work Address

Background Information

Child Resides With:

Level of Education: GED, High School Diploma, Graduate, or Post Graduate

Level of Education: GED, High School Diploma, Graduate, or Post Graduate

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Names of Sibling(s): (Full, Half and Step)

Names of Sibling(s): (Full, Half and Step)

Pregnancy, Birth, & Early Development

Pregnancy, Birth, & Early Development

Was the birth full term? 

Was the birth full term? 

Check all that apply:

Check all that apply:

Check all that apply:

Was mother under doctor's care?

Vaginal Delivery

Vaginal Delivery

C-Section

Forceps

Breech

Other Complications

Premature

Jaundice

Colic

Birth Defects

Breathing Problems

Feeding Problems

Sleeping Problems

Substance Exposed

Nicotine Exposed

Breast Fed

Bottle Fed

Special Formula

Vaginal Delivery

C-Section

Forceps

Breech

Other Complications