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Dreamplex Therapeutic School - Application

"*" indicates required fields

Student Information

Please enter the following information about the person participating in the program.
Which best describes the student?
Please enter the name of the school the student is transferring from.
Please enter the phone number of the school the student is transferring from.
Please upload student's most recent IEP and/or Progress Report Card.
Max. file size: 50 MB.
Student Name*
Date of Birth*
Gender*
Is the student bilingual or multilingual?
Address
Disabilities*
Please select any/all disabilities associated with the participant. (if applicable)
(Optional) Please add any other medical conditions related to the student not listed above. Feel free to expand on the participant's disabilities or any other information about the participant here. Include anything you would like the school teachers, aides, and therapists to know.
Is the student taking medications at home or school?
Please provide the names of medication required, what the medication is for, when and where it is given, how it is administered, etc.
Does the student have allergies to any of the following:
Which therapies does the student require?
(All students are expected to receive at least 2 therapeutic services through the Central Florida Dreamplex)
Primary Physician's Address
Specialist's Address

Family Information

Name of Primary Caregiver or Legal Guardian*
Please include a work number if applicable
Address (if not the same as student's address)
Name of Secondary Caregiver or Legal Guardian
Please include a work number if applicable
Address (if not the same as student's address)

Consent, & Payment

Consent*
By signing this form, I hereby authorize the school to submit my child’s application for $125.00 non-refundable application fee and use the information herein provided for the processing of my child's application. I understand that the information shared herein shall be for the purpose of the admission of my child. I authorize and provide consent to the school in releasing my child's medical and health information with the school's health services. If my child becomes ill, sustains an injury, or in any case, needs immediate medical care under the care and supervision of the school, I hereby authorize the school to administer first aid for my child's relief. In the event that my child needs immediate attention and it is not practical to wait for receiving instructions from the parents or appointed legal guardian or the child, I, as a parent/legal guardian, hereby authorize the school, its staff, to act as agents in delivering my child to a hospital and performing decisions necessary as recommended by an attending physician for the care of my child such as conducting X-ray and other medical treatments such as surgery. I further declare that the information I have provided in this form is true and correct to the best of my knowledge.
Select Card or Google Pay

Locations

Clermont:
2400 S Hwy 27 Suite B201
Clermont, FL 34711

Orlando:
5165 Adanson Street
Orlando, FL 32804

Office Hours:
Monday-Thursday: 8 AM-4 PM
Friday: 8 AM-2 PM

Phone: 352-394-0212
Email: info@cfldreamplex.com

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A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.
Registration # CH31939

Quick Connect

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SMS Disclaimer
By providing my phone number to “Central Florida Dreamplex, LLC” I agree and acknowledge that Central Florida Dreamplex, LLC may send text messages to my wireless phone number for any purpose. Message frequency will vary, and Message and data rates may apply. If you need further assistance, please reply “HELP”. You can also opt out by replying “STOP.” For more information on how your data will be handled, please see our privacy policy below:

SMS Privacy Policy Statement
No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

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