BEGAN IN 2005

For information call 323-965-7536

Please fill out information below & mail in for an intake/Eligibility appointment

Parent's Name: ___________________________________________________________________

Child's Name: ____________________________________________________________________

Address: ________________________________________________________________________

Age: ______ Grade: ________

School Attending: _____________________________________________ ____________________

Phone: ___________________________________ Fax: __________________________________

More information about your child:___________________________________________________

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