Tell Us About Your Student In an effort to be fully prepared to speak with you, possibly convene with the most relevant specialists from our staff for your student and make the most of an intake meeting, we ask that you help us prepare by filling out this brief form. Please provide confirmation you have received approval from your home district to seek an out-of-district placement.*You will need to get approval from your home district before we can proceed with your inquiry. Thank you for your interest and understanding. Yes Name of Parent/Guardian* First Last Name of Student First Last AgeAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Current School/ProgramWho/how were you referred to us?Describe your student's disability(ies):Is this student on the autism spectrum?YesNoPlease explain:What brings you to want to consider The Deron School?