Sessions With a ReSIT - Winter 2021 Application

Application for Sessions with a ReSiT

Please fill in the form below.
Today's Date

Month Day Year
Program: *

Winter Program w/ReSiT - 34 sessions, 2 sessions/week. Wednesday, January 27, 2021 through Tuesday, May 25, 2021
Student Name *

First Name Last Name
Nickname
Student Date of Birth *

Month Day Year
Student Pronouns *
eg. he/his; she/hers; they/theirs
Grade in School Year 2020-2021 *
School *
Primary Contact Name *

First Name Last Name
Primary Contact Relationship *
Primary Contact Address *

Street Address

Street Address Line 2

City State

Zip Code
Primary Contact Phone *

Area Code Phone Number
Primary Contact Email Address(es) *
Separate multiple email addresses with commas.
Secondary Contact Name

First Name Last Name
Secondary Contact Relationship
Secondary Contact Address

Street Address

Street Address Line 2

City State

Zip Code
Secondary Contact Phone

Area Code Phone Number
Secondary Contact Email Address(es)
Separate multiple email addresses with commas.
Has your child received any interventions at school? If yes, please describe.
Additional Student Information: *
Please tell us about your child with regard to reading. Do they like to read? What do you see at home? What are teachers telling you?
Please provide a copy of the student's evaluation, IEP, or both.

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Has your child worked with an Orton Gillingham practitioner?
How did you hear about us?
1st Choice of days/times *
2nd Choice of days/times *
2020/2021 Student Program Terms Conditions

Please Click on the box below, and Read and Sign Acceptance
Payment:
- Tuition is $1050 for the 34 sessions.
- Placement is not guaranteed. An invoice for the tuition will not be sent until a spot is confirmed.
Communication:

• You will receive progress reports from your student’s Specialist in Training by e-mail three times throughout the program.
Scheduling:
- Sessions begin at 5:00p.m. or 6:00 p.m. and are 55 minutes in length.
- Students are scheduled Monday/Wednesday or Tuesday/Thursday.
- Students must be available for all 34 sessions, barring illness or emergencies.
- Cancellations cannot be rescheduled.
Payment: *

Once a spot for my child has been confirmed, please send me an invoice for the entire tuition fee of $1050.
Print Name *
Date *
Signature *

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Application for Sessions with a ReSiT

2020/2021 Student Program Terms Conditions