Dyslexia and Dysgraphia Intervention Program

Dyslexia and Dysgraphia Intervention Program
Child's Name

First NameLast Name
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
Which Phase would you like to take?
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
Should be Empty: