DLE Trial Packet

Client Name *

First Name

Last Name

Session *

Which hours of support would you like?

AM Session: 8:45am - 12:30pm

PM Session: 1:45am - 5:30pm

Mailing Address *

This is where we will send curriculum packages

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Choose Your Supports *

These are the types of services you would like in you DLE program

Facetime with staff support (iPhone Required)

Phone Call with staff support

Curriculum Package

Google Classroom (must have computer/device and laptop)

Caregiver Support

Start Date *

When would you like to start

MM

DD

YYYY