Scholarship Request Form

It is our vision to have a world without reading failure. Thanks to scholarships funded by generous supporters, quality reading instruction can also be affordable.

All information is kept confidential and used solely in determining eligibility for financial assistance for requested DRC programming.

Service(s) Requested *
Contact Information
Student Name *
Student Name
Parent/Guardian Name *
Parent/Guardian Name
Address *
Address
Phone *
Phone
Household Income
$
Select One
Other Income:
Please check the box for any other income received by members of your household.
The total of income received from those sources listed above.
$
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.
Important: Before scholarship requests can be reviewed, a copy of your most recent W-2 must be sent to info@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 W-2 or other documentation of income to be eligible for scholarship funds.
By typing your name and date in this field, you agree to the Statement of Eligibility.