Please complete the form below to apply to be on Emerald Coast Learning Center’s waitlist.

Are you interested in learning more about Emerald Coast Learning Center for private school services? *

Gender *

Is student vocal? *

Augmented Communication Device? *

Potty trained? *

Describe maladaptive behaviors

Briefly describe student's communication abilities

Eligible for FESUA? *

Do they have insurance covering ABA in case 1:1 services are needed in clinic? *

Additional Notes