ACA Student Participation Form

ACA asks that you please use the form below to provide any relevant information about you (or the student you are completing this form on behalf of) so that we can learn a bit about you and ensure a positive classroom experience while at ACA. Thank you!

Student Contact Info

Student's First Name

Student's Last Name

Student's Preferred Name

Student's Pronouns

Student's Date of Birth

Primary Contact Cell Phone #

Primary Contact Alternate Phone #

Primary Contact Email Address

Student's Primary Language

Student's Secondary Language

Primary Contact Street Address

Primary Contact City

Primary Contact State

Primary Contact ZIP

Emergency Contact Info

1. Emergency Contact Name (First)

1. Emergency Contact Name (Last)

1. Relationship (Parent, Neighbor, Etc.)

1. Emergency Contact Phone

2. Emergency Contact Name (First)

Emergency Contact Name (Last)

2. Relationship (Parent, Neighbor, Etc.)

2. Emergency Contact #1 Phone

Student Information

Please use the section below to share any learning information and/or preferences that may help ACA provide a positive classroom experience for you/the student (i.e. health issues or concerns, learning styles and preferences, sensory sensitivities, etc.). Please use the section below to let ACA know how we can best meet your needs.

Please use the section below to share any health-related information that may help ACA provide a positive classroom experience for you/the student. Please use the section below to let ACA know how we can best meet your needs.

Emergency Contact Info

1. Emergency Contact Name (First)

1. Emergency Contact Name (Last)

1. Relationship (Parent, Neighbor, Etc.)

1. Emergency Contact Phone

2. Emergency Contact Name (First)

Emergency Contact Name (Last)

2. Relationship (Parent, Neighbor, Etc.)

2. Emergency Contact #1 Phone