CLASS REGISTRATION
First Name
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Middle Name
Last Name
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Date of Birth
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Do Not use slashes or dashes to separate.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
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Netherlands
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Other
Country
Gender
*
Male
Female
Last Grade Completed
*
Write, None, if starting Pre-K or Kindergarten
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Individual Child Profile
General Attitude / Personality Traits
Reluctant Learner - Excitably Curious
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*Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Reluctant Learner to Excitably Curious. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Fearful - Daring
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Fearful to Daring. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Compliant - Strong-Willed
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Compliant to Strong-willed. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Ambitious - Lazy
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Ambitious to Lazy. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Introverted - Extroverted
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Introverted to Extroverted. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Shy - Friendly
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Shy to Friendly. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Self-Reliant - Dependent
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Self-Reliant to Dependent. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Unmotivated - Achiever
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Unmotivated - Achiever. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Delayed Learner - Quick Study
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Slow Learner to Quick Study. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Competitive - Non-Competitive
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Competitive to Non-Competitive. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Sharp Memory - Forgetful
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Sharp Memory to Forgetful. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Distractible - Attentive
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Distractible to Attentive. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
Disorganized - Goal-Focused
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Please indicate on a scale of 1-5 this child's general attitudes and personality traits of Disorganized to Goal-Focused. Short comments are also welcome (i.e. when around adults, when stressed, etc...).
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Tell us a little more about your child:
When my child has free time, he/she will...
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Please describe how your child interacts with others:
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Briefly describe your child.
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Goals
Strengths: What do you see as your child's greatest strengths?
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Needs: What do you see as your child's greatest needs?
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Goals: What are your goals for your child this year?
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Long Range Goals: What are your long range goals for your child?
*
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Medical History
List all major health problems to date:
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Medications
*
List all medications currently being taken (including vitamins and supplements).
Medications - long term
*
List all medications that have been used for more than two weeks at a time (prescription and over the counter)
List any allergies
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Immunization Records AND Verified Non-vaccination record (most current):
*
Browse Files
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of
Insurance Card(s):
*
Browse Files
Cancel
of
Diagnosis. Please indicate any diagnosis/labels/disorders that have been used to describe your child. Select all that apply.
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ADD/ADHD
Dyslexia/Reading Problems
Auditory Processing challenges
Learning Disability
Autism Spectrum Disorder (including Asperger's)
Speech/Language Disability
Physical Disability
Developmentally Delayed
None
Other
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Family Profile
Tell us more about your family! This form is intended for curriculum design purposes only. This information will not leave Arete Academy and Learning Center
Parent Name:
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Parent Name:
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Best time to call between 9AM-5PM
*
Non-enrolling family members
Please list the name, age, and relation to student for non-enrolling family members living at home
What have been your "best" times as a family?
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What have been your "worst"times as a family?
*
Favorite family activities
*
What are you expecting us to do for your family?
*
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Learning Behavior Rating Scale
Indicates problem areas that you see in your child.
Problem Areas: Indicate any problems in the following areas. Check all that apply.
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Reading
Writing
Math
Spelling
Comprehension
Avoidance of school work
Works too hard
Slow worker
Reversal of letters or words
Loses place/ skips lines
Poor memory
Attention/ Concentration
Motivation/behavior
Low self-esteem
Overly active
None
Other
Help utilized: Please list any past or current help, training or tutoring utilized for the above problems.
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Learning & Behavior Rating Scale: Please read each of the following statements and rate this individual according to the following scale. Select your rating number using the given scale compared to others of the same age and gender for the behaviors listed:
Is careless.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Fidgets or squirms.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Swears or uses obscene language.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty maintaining attention.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Overreacts.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Loses temper.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has poor studying and work habits.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty organizing activities.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Leaves seat in class.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Argues with adults.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Reverses letters or words.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Fails to follow through on tasks.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Runs or climbs excessively.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Refuses adults' requests or rules.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Feels school work is too hard.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Takes a long time to complete tasks.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty playing quietly.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Deliberately does things that annoy others.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Does not complete school assignments.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Avoids prolonged mental effort.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Answers questions before they are completed.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Blames others for their mistakes.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty remembering.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Is distracted by other activities.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty waiting for turn.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
is angry and resentful.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty learning math facts.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Does not listen.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Is touchy or easily annoyed by others.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Hold grudges and seek revenge.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty with abstract concepts and reasoning.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Poor spelling grades or test scores.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Worries about future events.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Poor reading comprehension.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has poor handwriting.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Poor math grades or test scores.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Worries about past behaviors.
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0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Makes spelling errors in written assignments.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Squints, excessively blinks, or rubs eyes when reading.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Disliked school.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Is concerned about what others will think.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty sounding out unknown words.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty hearing.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Makes grammatical errors.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Is overly concerned about himself/herself.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Had ear infection or speech problems in the past.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has poor coordination.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Poor reading grades or test scores.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Needs reassurance in many areas of life.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Needs words repeated when taking spelling tests.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has speech difficulties.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Receives low test scores.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Complains about physical discomfort.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Avoids reading.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Complains about eye strain or fatigue.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty writing a paper.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Appears tense or unable to relax.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Reading is slow or choppy.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Is bothered by loud sounds.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has poor vocabulary.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Fears taking tests.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Has difficulty reading or spelling phonetically.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Skips words or lines when reading.
*
0 - occurs less often OR the question doesn't apply to the age of this person
1 - Occurs at about the same frequency
2 - Occurs slightly more
3 - Occurs considerably more
4 - Occurs significantly more
Tuition Packages
Please select between virtual and face to face learning to select the tuition package that works best for your family. Technology pack includes a pre-loaded Surface Go 2, a Microsoft pen, and a computer carrier bag. **Enrollment application will not be processed without a selected tuition package.
Virtual Learning
Full Tuition-$14,000.00
Full Tuition with Technology Package-$14,700.00
Face to Face Learning
Full Tuition-$17,000.00
Full Tuition with Technology Package-$17,700.00
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