Enrollment ILS Form

ENROLLMENT ILS FORM

Student Information

Date of Birth:

Parent / Guardian Information (if applicant is minor)

Program Enrollment Details

Requested Start Date:

In-person    Remote / Virtual    Hybrid    Home-based

Private pay    Insurance    School district funding    Scholarship / Grant

Eligibility & Documentation

The following documentation accompanies this enrollment (check all that apply):

Current IEP or individualized education plan    504 accommodation plan
Medical diagnosis documentation    Psychological evaluation    Academic transcript or report card

Medical & Emergency Information

Accommodations & Services Requested

Please indicate requested supports (select all that apply):

One-to-one instruction    Modified curriculum    Assistive technology    Behavior intervention plan
Speech-language therapy    Occupational therapy    Counseling / social-emotional supports

Financial Responsibility & Billing

Monthly installment plan    Pay per session    Full upfront payment

By checking the box below I acknowledge responsibility for all charges not covered by another payer and agree to the provider's billing procedures and deadlines.

I agree to be financially responsible under the terms above

Policies, Consent, and Acknowledgments

Eligibility verification: Enrollment is contingent on verification of submitted documentation and, when applicable, a program intake assessment. Services may be deferred until eligibility is confirmed and necessary records are received.

Confidentiality and records: The institution will maintain student records in accordance with applicable privacy and education-records laws. By enrolling, you authorize the exchange of records and communications with referring professionals, school districts, or insurers when necessary to deliver services, coordinate supports, or process claims.

Consent for services and emergency care: I authorize the provider to deliver the requested learning supports and interventions. In the event of an emergency, I authorize emergency medical treatment as reasonably required for the safety of the student.

Cancellation and absence policy: Cancellations within the provider's stated window or excessive absences may result in forfeiture of sessions or additional fees. The provider reserves the right to suspend or terminate services for noncompliance with policies or unsafe behavior.

Limitation of liability: To the extent permitted by law, the provider's liability for claims arising from services is limited to amounts paid for the specific service at issue. This limitation does not apply to willful misconduct or gross negligence.

Record sharing consent: I consent to the release and exchange of educational and medical records as necessary to provide services and coordinate care.

Medical consent: I authorize emergency medical care if required for the student's safety.

Acknowledgement of policies: I have read, understand, and agree to the terms, policies, and acknowledgments contained in this enrollment form.

Additional Information

Certification

I certify that the information provided on this Enrollment ILS Form is true and complete to the best of my knowledge. I understand that intentional misrepresentation may result in denial of services or termination of enrollment. I agree to notify the provider promptly of any material changes to this information.

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