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Apply for Learning for All's Dyslexia Initiative Program

Name of Student

First Name (Parent/Guardian #1)

Last Name (Parent/Guardian #1)

Street Address (Parent/Guardian #1)

Street Address Line 2 (Parent/Guardian #1)

City (Parent/Guardian #1)

Region/State/Province (Parent/Guardian #1)

Postal / Zip code (Parent/Guardian #1)

Phone (Parent/Guardian #1)

Email (Parent/Guardian #1)

Occupation (Parent/Guardian #1)

First Name (Parent/Guardian #2)

Last Name (Parent/Guardian #2)

Street Address (Parent/Guardian #2)

Street Address Line 2 (Parent/Guardian #2)

City (Parent/Guardian #2)

Region/State/Province (Parent/Guardian #2)

Postal / Zip code (Parent/Guardian #2)

Phone (Parent/Guardian #2)

Email (Parent/Guardian #2)

Occupation (Parent/Guardian #2)

Number of Dependents in Household

List All Siblings Names and Ages (Please separate with a comma. Example: John age 13, Jane age 15)

Party Responsible for Payment

Total Household Income

Presenting concerns and/or previous diagnosis:

Please write a brief statement describing your child and why you should be considered as an applicant for this Initiative

Offerings of reduced rates are at the sole discretion of Learning for All, Inc. and are not guaranteed. Applicants must remain in good financial standing and abide by all of the policies set forth in the Service Agreement in order to participate in this program. Applicants must commit to the entire service period (Fall, Spring, or Summer) in order to be considered for a Dyslexia Initiative rate.

I understand and agree to these policies:

Your Signature

Select a date required