Prospective Student Information Form

Thank you for your interest in the Dyslexia Resource Center. Please complete and submit the form below. Once we have received your completed Prospective Student Information Form, we will be in contact within two business days with recommended “next steps”.

If you are concerned we did not receive your form, please email us at info@dyslexiasc.org.

What Services are you Interested In
GENERAL INFORMATION
Child's Name *
Child's Name
Gender
Birthdate
Birthdate
Parent/Guardian's Name
Parent/Guardian's Name
Best Contact Number
Best Contact Number
Mailing Address
Mailing Address
YOUR CHILD'S ACADEMIC HISTORY
Homeschooled?
Does your child have
Check all that apply
YOUR CHILD'S HEALTH HISTORY
Food? Other? Asthma?
Please list number of people and their relationship to the family.
Parent and/or teacher's observations:
Both at home and at school: