Service(s) Requested

Initial Assessment

Tutoring (Must be updated yearly)

Contact Information

Student Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Household Income

Total Household Income

Select One

Weekly

Monthly

Yearly

Employer Name(s):

Other Income:

Please check the box for any other income received by members of your household.

Social Security

Public Assistance

Food Stamps

Child Support/Alimony

Other

Total Other Income:

The total of income received from those sources listed above.

Please include any other information you would like us to know about why you are requesting a scholarship.

Notice of Electronic Communication

We frequently use email as an efficient way to communicate with families we serve. This includes, but is not limited to, managing requests for services, scholarships and appointments, communicating progress regarding your child's skills, and sharing assessment reports. Standard e-mail services such as Gmail, Hotmail, etc. are not encrypted and can be intercepted and read by unauthorized individuals. We will do our best to ensure that we have your correct email address and ask that you do the same. Please acknowledge below if you agree to communicate electronically with The Dyslexia Resource Center.

Yes, I agree to electronic communications from the Dyslexia Resource Center.

Important: Before scholarship requests can be reviewed, a copy of your most recent tax form showing your adjusted gross income must be sent to accounting@dyslexiasc.org. Documents can be scanned or a picture can be taken with a mobile device. Be sure to note your student’s name when submitting paperwork.

Statement of Eligibility

I do hereby swear that the information provided on this application is true and correct to the best of my knowledge. If a scholarship is obtained, I agree to comply with all rules and regulations of The Dyslexia Resource Center including disclosure of a substantial change in income during a scholarship period. I understand that a new scholarship request may be required for future programs, that no guarantees or promises have been made that my child will receive a scholarship and that scholarship funds are non-refundable and non-transferable. I agree to provide a copy of my most recent 1040 showing adjusted gross income (AGI) or other documentation of income to be eligible for scholarship funds.

Electronic Signature

By typing your name and date in this field, you agree to the Statement of Eligibility.

Thank you for completing a Scholarship Request form. Please remember to send a copy of your most recent tax return showing your AGI (Adjusted Gross Income) to accounting@dyslexiasc.org.

Once all required information is received, your request will be processed within three business days.

Need-based assistance Request for drc services

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