Dyslexia and Dysgraphia Intervention Program

Dyslexia and Dysgraphia Intervention Program
Child's Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Date
Age of the Child:*
Address*
Mother*

NamePhone Number
Father*

NamePhone Number
Contact Email Address*
example@example.com
Emergency Contact*

NamePhone Number
Phase 1 – September – DecemberPhase 2 – January – MarchPhase 3 – April – June
Number of sessions per term: 24 sessions
Number of sessions per week: 2 sessions
Duration of a session: 1.5 hours
Terms and conditions: Fees are due within five days of receipt of registration. The fees are non-refundable and make-up sessions are not provided for any absence.
How did you hear about the program?*
Name and Signature*
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