Admissions Interest Form

Admissions Interest Form
Child's Name*

First NameLast Name
Child's Date Of Birth*

MonthDayYear
Date
Parent or Guardian's Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Best number to reach you
Address*

Street Address

CityState

Zip Code
How did you find out about us?*
What type of program are you interested in for your child?*
Name of Friend/Family Member who referred you to FLS:
Preschool Special Education
Lemmon Tree Academy (LTA)
Private elementary school for children with disabilities.
Name of Child's Current Case Manager with WCPSS
NOTE: If your child will be accessing our program through one of our community partners (WCPSS, NCPK), we will assist you in coordinating with their office regarding placement.
- Current WCPSS students should connect with their child's case manager (current teacher) to discuss.
- Families going through the process to obtain an IEP should discuss their interest in FLS with their case manager at the Office of Early Learning.
- Families interested in NCPK must complete the application process through Wake Smart Start. NCPK students can only be enrolled after they are placed by Smart Start.
Services your child is currently receiving, is waiting to receive, or previously received:*

Childcare (part-time program)Childcare (full-time program)Speech TherapyOccupational TherapyPhysical TherapyFeeding TherapyABA TherapyVision TherapyNone
Admissions Process Acknowledgments*
Please upload a copy of current IEP/IFSP and/or any therapy assessments/progress reports for your child:

Cancelof
Any additional information you would like to share with our admissions team?
Submitted:
Should be Empty: