Large Call to Action Headline

Step 2 For Visit Day

Information Form For Each Child

Next, we would like to learn about the specific needs of each of your children.

Complete one form for each child, and then click continue to calendar button below to schedule your visit day.

COMPLETE 1 FORM PER CHILD

READ: Please fill this out as honestly as possible. We ask for this information to get an overview of your child's needs.

-Read EACH ITEM on the list carefully.

-Do not skim the list. This is vital to help us know how to serve your family.

Please note that clicking items below does not indicate that your child will not be a fit for Acton, although there are some special learning needs that we can not serve at Acton.

****This form helps us to know if there are items that we need to further discuss with you in order to determine if we can serve your child.

QUICK CLICK FORM (1 PER HERO)

Please fill this out as honestly as possible. We ask for this information to get an overview of your child's needs. Please note that clicking items below does not indicate that your child will not be a fit for Acton, although there are some special learning needs that we can not serve at Acton. This form helps us to know if there are items that we need to further discuss with you in order to determine if we can serve your child.

I understand the following about choosing an Acton Eduction: *

Acton is not a short-term "fix" for my child.

Acton is a "long game" training ground for how to create and live a fulfilling life.

Acton is not just a school, it is a lifestyle that requires changing and growing for parents & children.

I understand that our family success at Acton may require significant shifts in our family culture, such as: eliminating video games and screen time and increasing quality family time.

Parent #1 Full Name *

Email *

Parent #2 Name

Parent #2 Email

Parent #2 Phone

Child Name *

Child's Age *

Date of birth *

Grade *

What location are your auditioning for? *

What would you say is your child's general disposition toward life? *

Please mark all that apply: *

My child watches more than 5 hours of TV/Netflix/Youtube/Disney+/etc. per week (apx. 1 hour/day)

My child has a cell phone.

My child has access to social media (Instagram/Tiktok/Facebook/etc.)

My child plays video games (on any of the following: console/cell phone/tablet/computer/other) on an average of four days/week.

My child uses/has experimented with vaping, smoking, alcohol or other addictive substances.

My child knows (because we have discussed it) about the dangers of pornography and being safe online.

None of the above

Does/would your child require an IEP (Individualized Education Plan for special education/related needs) in traditional public school? *

Yes

Do you suspect (or have a diagnosis) of ADD, ADHD, ODD, Dyslexia, or Autism for this child? *

ADD-attention deficit disorder

ADHD-attention deficit hyperactivity disorder

ODD-oppositional defiant disorder

Dyslexia-difficulty reading, retaining letter information, mixes up letter order

Autism/on the spectrum

Other

I DO NOT suspect ANY of the above or have a diagnosis of any of the above listed

What do we need to know about your child to serve them well? Please mark all that apply. *

Allergies

Fears/Anxiety

Developmental Challenges

Unique Medical Needs/Medication

Previous Classroom Challenges-Behavior, Bullying, Social

Participated in "gifted" or specialty programs in school

Court issued mandates/directives concerning education

Lives in two different households during the school year

None of the above apply.

ACTON LEADERSHIP GUARANTEE: We promise that your child will be empowered with tools to live a fulfilling life, become a more confident problem solver & communicator, and that your family will grow together.

I understand that the Acton Leadership Guarantee is conditional upon the following actions from me, as a parent of an Acton Hero:

We uphold our ALA Parent Contract, especially including the following:

a) attend Acton parent meetings

b) complete Acton parent badges

c) limit video games and social media

d) We, as parents actively further my/our own growth and learning journey

Our Hero attends and fully participates in Acton Leadership Academy for two or more consecutive years.

***Be sure to answer each question. If you hit "submit" and nothing happens, you have likely missed a question. Each question requires a response. Thank you.

By signing, I promise that I have answered the questions above with 100% integrity and to the best of my parental instinct, responsibility and knowledge. *

Clear

Please be sure to complete one Quick Click form per child, and then click continue to calendar to schedule your visit day!

CONTINUE TO CALENDAR TO SIGN UP FOR YOUR VISIT DAY---><----BE SURE TO COMEPLETE A QUICK CLICK FORM FOR EACH CHILD!