Admissions information sheet

Parent/Legal Guardian essentials
Parent/Guardian #1 e-mail address *
Parent/Legal Guardian #2 e-mail address (if they wish to receive correspondence and results)
example@example.com
Preferred Phone *

- Area Code Phone Number
Alternate Phone *

- Area Code Phone Number

Mailing Address *

Please list the schools to which you would like results sent. You can always call or email directly to add to this list. *
It is not necessary to include Admissions contact information. Results are sent to you and to the school(s) simultaneously.
Please provide your consent to send results in the following formats *

email fax
I would like expediting if available (results within 4 business days) for an additional fee of $75.00 Please note that tester will confirm availability, as this feature is schedule-dependent.

Yes No
We do not test sick children. If your son or daughter is within the first 48 hours of taking a prescribed antibiotic, has a rash or viral infection, or has vomitted or had a fever within 72 hours, we require rescheduling. We are dedicated to finding a spot for you when your little student is feeling better!
If a school contacts us to discuss the test findings, we would like permission to do so. If you are agreeable, please indicate. *

Yes No
If you know, please indicate who will be accompanying your child to the appointment:
How did you hear of Washington Psychology Associates? *
Appointment status *

I have made an appointment I have not made an appointment and need help
Parent's signature indicating acknowledgment of the policies reviewed in this document, truthful reporting, agreement to pay associated fees, and consent to evaluate:
Signature

Clear
Parent's full name

First Name Last Name
Should be Empty:

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Name
Class (if applicable)
Days per week	Primary Language
Secondary Language (if applicable)	Country

Please take a few minutes to complete this form.