Service(s) Requested

Tutoring 2024 - 2025

Student Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Select One

Weekly

Monthly

Yearly

I have applied for the South Carolina "Education Scholarship Trust Fund Program"

Yes

No

I have been approved for the South Carolina "Education Scholarship Trust Fund Program"

Yes

No

Not Yet

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

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.