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Application fee

Application fee^*

I have read the statement below and will submit my fee payment online to Exceptional Minds. I acknowledge that my application will not be processed until my application fee is received in full.

There is a one-time application fee of $65.
Your application will not be reviewed until we have received payment. Application fees can be paid through Zelle using the email info@exceptional-minds.org

Student Information

Today's Date^*

Returning students only

Please check here if you are a returning student.

First Name^*

Middle Name

Last Name^*

Preferred Name

Date of Birth^*

Legal Sex^*

Gender Identity (optional)

Man Woman Self Identify

Gender Self Identity

Optional

Preferred Pronouns

Citizenship^*

Please explain citizenship if other

What is your ethnicity?

If you took a tour of Exceptional Minds, when did you complete your tour?

Full-Time Program: Receiving funding to participate in our full-time program can be an extensive process. Please tell us if you potentially intend to apply to our program next fall so we can follow up with potential options for you/your student. ^*

Student Contact Information

Street Address ^*

Apt./Unit #

City^*

Zip Code^*

State^*

Country^*

Student Email^*

** If student is a minor, please enter primary Parent/Guardian email address.

Phone Number^*

In which of our programs are you interested? Check all that apply.

Full Time Summer Workshops Saturday Workshops Private Lessons Extension Programs

What are your career goals?

What are the areas you would like to know more about?

How did you hear about Exceptional Minds? Please select one from the drop-down menu?^*

LinkedIn Profile Link

Please include a link to your LinkedIn profile. If you do not have a LinkedIn profile, please put N/A.

Portfolio Link

Please include a link to your portfolio, if applicable.

Please include any social media handles you use. If none, enter N/A.^*

Family Information

Parent/Guardian 1 - First Name^*

Parent/Guardian 1 - Last Name^*

Relationship to Applicant^*

Address Same as Applicant^*

Address if Different than Applicant

Phone Number^*

Email Address^*

Parent/Guardian 2 - First Name

Parent/Guardian 2 - Last Name

Relationship to Applicant

Address Same as Applicant

Address if Different than Applicant

Mobile Phone

Home Phone

Email Address

Emergency Contact Information

Emergency Contact Information. Please select one option from the drop-down menu.^*

Secondary Emergency Contact - First Name

Secondary Emergency Contact - Last Name

Relationship to Applicant

Address Same as Applicant

Address: If Different than Applicant

Home Phone

Mobile Phone

Email Address

Education Information

Please select one of the following for school status^*

Name of Post-Secondary/College/University (if applicable)

Dates Attended

Credit, Certification, or Degree Achieved (if applicable)

Have you ever been suspended or expelled from any school?^*

If yes, please explain

Background Information

Have you been formally diagnosed with Autism or Autism Spectrum Disorder (ASD)? ^*

If yes, please specify diagnosis.

Do you receive services or benefits from any of the following?^*

If other agency, please specify.

If you receive funding from the regional center, is it with self determination funding?^*

Are you reimbursed by the regional center for the programs you’ve participated in or do you receiving funding beforehand for programs?^*

Are you legally conserved? If applicable, please upload Letters of Conservatorship in Required Documents section.^*

If yes, what is your conservator's first and last name?

What is your conservator's email address?

Do you have any health conditions or allergies that we should know about?

If yes, please explain.

Please list any medications you take, including prescribed purpose and dosage.^*

Put N/A if this does not apply to you

Consent to Disclose and Exchange Information

In accordance with the Family Educational Rights and Privacy Act (FERPA), Exceptional Minds (EM) may only release student records directly to the student, unless prior authorization is given by the student.

**Consent is needed for students 18 years or older. If you are a minor, please select the minor option from the drop down.**

Consent to Disclose Information to Parent(s)/Guardian(s)^*

This written consent will allow parent(s)/guardian(s) listed below to access your performance evaluations,
testing records, and behavior reporting. Information will be released orally or in the form of copies of
written records. Prior to release of any written records, you will have the right to review. This authorization will remain in effect for the duration of your time at EM both as a student or an employee. You may revoke at any time by providing written notice to EM. Please sign below if you choose to allow or not allow EM to disclose information to your parents.

Parent/Guardian 1 (first and last name)

Parent/Guardian 2 (first and last name)

Today's date^*

Consent to Disclose Information to Agencies^*

This written consent allows agencies and representatives to exchange information with one another including but not limited to: medical and health, developmental, speech and language, and behavior. Please indicate which agencies may exchange your personally identifiable information. All information will remain confidential among parties.

Psychiatrist/Medical doctor

Psychologist/therapist

Regional Center/DOR

Other

Please provide specific instructions related to information sharing with agencies/representatives.

Today's date^*

Consent to Disclose Information to the Department of Social Services^*

I acknowledge that EM will give such information if requested by the Department of Social Services.

The Department of Social Services may request to verify Social Security Supplemental Income or
disability benefits under the Social Security Act. It is Exceptional Minds’ duty to assist with providing
corresponding records and documentation.

Today's date^*

Photo/Audio/Video/Website Release^*

Photographs, video, and/or audiotapes to be taken of me/the student, may be used in Exceptional Minds movies, websites, documentaries, news releases, social media and other promotional materials.

Independent Transportation Release for Field Trips (Conserved Students Only)^*

Method of transportation

Today's date^*

Required Documents

Proof of Formal Diagnosis^*

Most recent IEP (Individual Education Plan), Doctor's letter, psychological assessment,

Letter of Conservatorship

Required if conserved

High School Diploma

For Full-Time Applicants

Most Recent School Transcript

If applicable

Statement of Authenticity

Statement of Authenticity^*

The information provided on this application is true to the best of my knowledge.

This Application Was Completed By: ^*

What is the primary email where you would like to receive correspondence? ^*

Submit Application

You must agree to Exceptional Minds Behavior Policy to complete your application.

https://docs.google.com/document/d/e/2PACX-1vRxAsUddA7JytvABwkL0NKNucsoQYxnEqm84ul4i1dukxedJPzjV6_WRtSX3xG6ZdceZFFJqNBwXDws/pub

Please accept the terms & conditions to submit this form.

Application

Application fee

Student Information

Student Contact Information

Family Information

Emergency Contact Information

Education Information

Background Information

Consent to Disclose and Exchange Information

Required Documents

Statement of Authenticity

Submit Application

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