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PIONEERS Homeschool Co-op

PO Box 6425, (637 W. Ganson St.)

Jackson, MI 49204

(517) 888-4328

If you are unable to find the information that you are looking for on the website, or if you have a question for us, please feel free to contact us using this form and we will get back to you as soon as possible.

1. *	Parent(s) Name:

2. *	Student(s) Names:

3. *	Age and grades of your children (as of Sept. 1st) - (so we know which program that you may be interested in).

4. *	Address, City, State, Zip Code:

5. *	Phone Number:

6. *	Email Address:

7. *	Church Affiliation:

8. *	Name of your Pastor:

9. *

Is this your first year homeschooling?

Yes

10. *

Current School:

Years in this school:

Phone Number of school:

11. *

So that we may better serve your child, does your child have any learning disabilities or dyslexia?

If yes, please explain.

12. *

Will your child be attending public school or receiving auxillary services (Speech Theraphy, etc. from the public school at any time this year? (Please type Yes or No)

If so, how many hours/classes?

13. *	How can we help you?