EBC Inquiry Form - The School of Acrobatics and New Circus Arts

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EBC Inquiry Form

Student's Name*
First Last
Student is*
- An adult, 18 years or older
- A child, younger than age 18
Student's Birthdate*
Month
Day
Year
Contact Info
Parent/Guardian Name*
First Last
Primary Phone*
Primary phone is
- Cell/Mobile
- Home or Work
Secondary Phone
Primary Email*
Emergency Contact Name
First Last
Emergency Contact Phone
More about you
Why are you interested in the Every Body's Circus Program?
Is there any relevant information that could affect participation in a circus class (i.e.: medication, diagnoses, or medical conditions)? Please provide any information you are comfortable with sharing.
How were you referred to SANCA?*
More About the Student
Has this child taken circus classes before?*
- Yes
- No
Is this child on any medications?*
- Yes
- No
Does this child have any diagnoses? Please describe
Does your child have a one-on-one aide?*
- yes
- no
How verbal is your child?
Please tell us about your child’s interests
Please describe any social issues/needs of which we need to be aware
Please describe any medical needs/history of which we need to be aware
Please describe this child's behavioral/emotional history
What would you like to have this child get out of an Every Body’s Circus offering?
- Have fun
- Learn circus skills
- Learn social skills
What helps this child when they are feeling overwhelmed?
Is there anything else we should know about this child?
Name
This field is for validation purposes and should be left unchanged.

Δ

Thank you for completing this EBC inquiry form.
While the EBC programs are on summer break, submissions are held in the order received and will be answered in that order in the fall

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Seattle, WA 98108
(206) 652-4433
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