Student Client Checklist

STUDENT CLIENT CHECKLIST

Student Information

Date of Birth:    Student ID:    Grade / Program:

Parent / Guardian (If Student Is a Minor)

Is student a minor?    Parent/Guardian Name:

Emergency Contact & Medical

Relationship:    Phone:

Required Documents Checklist

Proof of identity (government or school ID)
Immunization record
Most recent transcript or report card
IEP / 504 plan (if applicable)
Proof of residency / guardianship documents
Other documents submitted

Services Requested / Program Details

Services requested (check all that apply):
Tutoring / Academic Support
Counseling / Advising
Accommodations / Special Education Support
Extracurricular / Enrichment Programs

Financial / Payment Information

Estimated Tuition / Fees: $    Preferred Payment Plan: Full payment    Monthly installments

Consent, Authorizations, and Release

I authorize provision of the services identified above and consent to school personnel delivering or coordinating those services as described in program materials and applicable policies.
I authorize release of educational and health records to staff or collaborating providers as necessary to deliver services and to coordinate care, consistent with applicable federal and state privacy laws.
I consent to the use of non-identifying photographs or recordings for educational or program documentation unless I mark the opt-out below.
I do NOT consent to photo/video use.

For activities requiring transportation, I authorize the student to be transported by authorized personnel or approved vendors and accept responsibility for any associated fees.
If in the opinion of school personnel an emergency requires immediate medical attention, I authorize the school to secure medical treatment and agree to be responsible for expenses related to such care.

Policies Acknowledgment

By checking the box below and signing, I certify that the information provided on this checklist is complete and accurate to the best of my knowledge. I acknowledge receipt of and agree to abide by applicable attendance, conduct, fee, cancellation, and privacy policies. I understand that falsification of information may result in denied services or disciplinary action.

I acknowledge and accept the policies and statements above.

Additional Notes (Intake Use)

Certification and Signature

I certify that I am authorized to enroll or request services for the student named above. I attest that the information supplied is true and accurate. I understand that by signing below I am authorizing the school or program to take actions reasonably necessary to provide services, to obtain emergency medical treatment if required, and to exchange records with appropriate providers as described in this form and permitted by law.

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