Date Received:_______________

Child Name: _______________________________________________________________ Sex: _____ Age: ______ DOB: ____________

Parent(s): ________________________________________________________________________________________________________

Home Address: ___________________________________________________________________________________________________

E-mail: __________________________________________________________________________________________________________

Check One:

____ $200.00 Tuition Fee Enclosed                 ____ $200.00 Tuition Fee to be Paid at Parent Orientation

School Last Attended: __________________________________________ Grade Next Year: ________

Upon acceptance, parents will receive confirmation of acceptance and a program-planning packet. Please complete the requested information
in the packet and return to the address above as soon as possible. 
 

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I authorize ___________________________________________ (School System) to release to Auburn University’s RSED Autism Summer

Clinic a copy of the current IEP and other current reports and testing protocols to assist in summer program planning for:
 
 

________________________________________ (Child) _________________________________________ (Parent Signature & Date)