Special Education Scheduling Poll
Help us coordinate special education sessions by sharing your availability and preferences.
Student Full Name
*
First Name
Last Name
Parent/Guardian Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Student
*
Please Select
Parent
Guardian
Self (Staff)
Other
Preferred Session Format
*
In-person
Virtual/Online
No preference
Please select all special education services needed
*
Speech Therapy
Occupational Therapy
Physical Therapy
Academic Support
Behavioral Support
Other
Weekly Availability for Sessions
*
Rows
Morning (8am-12pm)
Afternoon (12pm-4pm)
Evening (4pm-7pm)
Monday
1
2
3
Tuesday
4
5
6
Wednesday
7
8
9
Thursday
10
11
12
Friday
13
14
15
Preferred Session Duration
*
30 minutes
45 minutes
60 minutes
Other
Are transportation services required?
*
Yes
No
Primary language spoken at home
*
Please Select
English
Spanish
French
Other
Additional Comments or Special Considerations
Submit Scheduling Preferences
Should be Empty: