Parent/Guardian Info
Email
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Phone
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Preferred Contact Method
Phone
Email
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Student Info
Grade Level
Age
School
Does your child have an IEP or 504 Plan? (Yes/No)
Briefly describe your child's reading needs or goals.
Program Interest
What are you interested in joining?
Small Group Classes K–2nd Grades
Small Group Classes 3rd–5th Grades
Small Group Classes 6th–8th Grades
Small Group Classes 9th–12th Grades
Semi-Private 2:1 Sessions
Either Small Group or Semi-Private is fine
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Availability for Sessions; Please select all days and times your child is available for weekly sessions:
Morning = 8:00 AM to 12:00 PM
Afternoon = 12:00 PM to 4:00 PM
Evening = 5:00 PM to 8:00 PM
Monday
Morning
Afternoon
Evening
Tuesday
Morning
Afternoon
Evening
Wednesday
Morning
Afternoon
Evening
Thursday
Morning
Afternoon
Evening
Friday
Morning
Afternoon
Evening
Current Reading Skills Check all that apply:
My child knows all letter names
My child knows all consonant sounds
My child can read 1-syllable short vowel words (e.g., cat, hop, bed)
My child can read 1-syllable long vowel words (e.g., cake, bike, road)
My child can read 2-syllable short & long vowel words (e.g., basket, raindrop)
Additional Notes
Is there anything else we should know to help us match your child with the right group or session time?
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