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The Faison School
1701 Byrd Avenue
Richmond, VA 23230
Phone: 804.612.1947
Fax: 804.612.1955


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Application

I. General Information

Address:
City, State, Zip:
Phone(s):
home
 work


Address #2:
City, State, Zip:
Phone(s):
home
 work


E-mail Address:
Pager/Cell Phone:
Preferred Contact:



Name of Child:

Date of Birth:
School District:
Primary Caretaker(s):
Relationship to Child:


Sibling #1 Name:

Date of Birth:


Sibling #2 Name:

Date of Birth:


Sibling #3 Name:

Date of Birth:


Sibling #4 Name:

Date of Birth:


 

II. Reason for seeking placement at The Faison School

 

III. List educational programs in which child has participated
(list most recent first)
1. Name of Program:
Location:
Dates Attended:
Type of Services Received:
Hours of Services Received:
Adult to Child Ratio:
Comments:
2. Name of Program:
Location:
Dates Attended:
Type of Services Received:
Hours of Services Received:
Adult to Child Ratio:
Comments:
3. Name of Program:
Location:
Dates Attended:
Type of Services Received:
Hours of Services Received:
Adult to Child Ratio:
Comments: