Waitlist Application

Waitlist Application
Please complete this form and we will notify you when enrolment opens.

If a regular session becomes available, we will get in touch with you using the contact details you provided in this form. If you're not available, we'll try to contact you again but if we cannot reach you in 24-48 hours, we'll contact the next in the queue.
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*
Please enter a valid phone number
Parent/Guardian Email*
example@example.com
How did you hear about ClarityWorks? *
eg. family/friend/practitioner referral
Participant Information
Child Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Grade Level*
School*
I am interested in:

Dyslexia InterventionDyscalculia InterventionLiteracyMathsExtension (gifted/talented)Other
Please let me know a little bit about your child, their learning needs, and why you would like the support of ClarityWorks. *
Details of current interventions (if relevant):
Availability
Due to the 1:1, completely individualised service provided by ClarityWorks, availability is limited. Sessions are offered to participants based on their position on the waitlist, and their availability/flexibility. Participants available for sessions during the day will be more likely to secure a session sooner. Please specify your availability below (you may choose more than one option). I am interested in sessions:*

during the daybefore schoolafter school
I understand that completing this form does not secure a place at ClarityWorks. Sessions are strictly subject to availability and offered depending on position on waitlist.*

I understand
Today's date:

MonthDayYear
Date
By submitting this form you are giving permission to ClarityWorks to subscribe you to our newsletter/blog as well as to contact you via email or phone when enrolment becomes availabile. Do you consent?*

Yes
Please verify that you are human*
Should be Empty:

Waitlist Application

Parent/Guardian Information

Participant Information

Availability