Allergies to food, medication or insects (please specify):*

Has your child experienced any serious illness or accident? (Give dates and nature of illness or accident)

Is your child receiving any therapy or early intervention services?*
Select...Speech TherapyOccupational TherapyPhysical TherapySEIT SupportOtherNone

If your child has an IEP, please provide a copy with their application:

What are your child's leisure activities and interests?*

Additional information on your child's behavior, habits, and temperament:*