Registration

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www.stridesofexcellence.com

Circle Service of Interest

Educational Advocacy                                           Customized Tutoring                                    Home Behavior Management Intervention

Print Rich Infused Home                                       Educational Planning                                    *Diagnostic Educational Assessments

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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

Premature

Jaundice

Colic

Birth Defects

Breathing Problems

Feeding Problems

Sleeping Problems

Substance Exposed

Nicotine Exposed

Breast Fed

Bottle Fed

Special Formula

Developmental Milestones 

Place the age child met developmental milestone:

First Steps

Spoke single words

Fully toilet trained

Identified colors

Walked without help

Identified letters

Spoke in phrases

Medical History

Check all that apply:

Balance Problems

Emotional Problems

High Fevers

Medication

Mental Illness

Convulsions

Ear Infections

Memory Difficulties