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CONTACT INFORMATION
     Name:   
     Relation to Student:  
     Telephone:  
     Email:  
     Contact Preference:   PhoneEmail
     How did you hear about us?  
     Are you located in Indiana or Armstrong county, Pennsylvania?  

STUDENT INFORMATION
     Student Name:   
     Student's School:  
     Student's Age:  
     Student Currently Has:   IEP504 Plan

PRESENT CONCERNS LEADING TO ADVOCATE INTAKE
Please describe in detail what steps you have taken prior to reaching out to The Arc to alert those working with your student about your concerns and possible solutions with your IEP/504 team, teacher, principal, or Special Education Director
     


Please describe in detail the concerns and goals you would like to address to ensure your student's educational success:
     

CONTACT INFORMATION
     Name:   
     Email:   
     Telephone:  
     Contact Preference:   PhoneEmail

CONCERNS
Please describe in detail the questions / needs / concerns and other information to include so that we can best assist you
     

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