Name of Student *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Programs of Interest *

Select all that apply.

Small Group: Intensive Reading Program

Private 1-on-1: Intensive Reading Program

Private 1-on-1: Intensive Math Program

Private 1-on-1: Dyslexia Therapy

# of Classes per Week *

2 Days/Week (Mon/Wed or Tues/Thurs)

4 days/Week (Mon - Thurs)

Small Group 4 days/Week (Mon-Thurs)

Parent/Guardian Name *

First Name

Last Name

Phone *

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