Reading Consultation Registration Form
Includes Free 30-minute Reading Consultation
Name
*
First Name
Last Name
Parent or Guardian (if under 18)
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Grade Level
*
How did you find me?
*
Shore Website/Management Office
Friend/Family Member
Facebook
Instagram
Google
Learning Aid Ohio Provider List
ACE Marketplace
Community Newspaper
Other
What is your time zone?
*
Eastern Time
Central Time
Pacific Time
Other
Type of schooling?
*
Homeschool
Private School
Public School
Virtual Public School
Could you please provide a detailed list of the specific reading challenges your child has been experiencing?.
*
In terms of your child's reading journey, what are some of the key goals you have in mind for their improvement and growth?
*
Could you share some insight into your child's emotional relationship with reading? How do they generally perceive and approach reading activities?
*
Which tutoring session length works best with your son's or daughter's schedule?
*
30 minutes
60 minutes
Are you interested in group lessons (2-3 children with similar reading challenges)?
*
Yes
No
Maybe
Is there anything else you’d like me to know?
*
I’d like to stay in touch with you! I promise to only send you emails or text messages regarding being a student of my class or information which will have value to you as a student or parent. By providing your email address and telephone number, you agree to receive emails and text messages from Engaged Minds Educational Services.
*
Yes, I agree to be added to the email list and receive text messages. I understand I can opt out at any time.
No, I do not want to be added to the email list or receive text messages.
Submit
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