Expression of Interest Application

Expression of Interest

Please complete this form to express your interest in the ClarityWorks Literacy Intervention program.
I'm excited to invite you to be an exclusive part of my literacy intervention program. As this is the first intake, your child will gain access to the the tools they need to succeed in reading at a special reduced price.

This is an obligation-free expression of interest, so please complete the form in order to be considered for the program.

Let's embark on this literacy adventure together!

If your application is successful, you will be notified of all details when the program is ready to go!
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 here because: (please mark all that apply)

I was referred by a professionalI was referred by a friendTo build my child's confidence in reading and writingMy child could benefit from literacy intervention/tutoringMy child has learning difficulties (such as dyslexia, ADHD, ASD and/or anxiety)I suspect my child has learning difficultiesI want my child to be meeting school targets and be up to speed with their classmates and/or I don't want them to fall behind.Other
I would like my child to be placed on the cancellation list, where they can receive 1:1 intervention at a reduced rate, if another child cancels their regular session.

YesNo
Please let us know a little bit about your child, their learning needs, and why you believe my literacy intervention program would benefit them. *
Details of current interventions (if relevant):
Eligibility
I understand that completing this form does not secure a place in the ClarityWorks Literacy Intervention program. Places are limited and strictly subject to availability, offered depending both on suitability for the program and position on waitlist.*

I understand
I understand that the ClarityWorks Intervention program is currently in development, and I will be notified when it is complete.*

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 in the Beta course becomes available. Do you consent?

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

Expression of Interest

Parent/Guardian Information

Participant Information

Eligibility