Student
Which of our locations will your student be attending?
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West University - 2014 Bissonnet Street, Houston, TX 77005
Memorial - 9409 Katy Freeway, Houston, TX 77024
Pick a Time for BRIDGES: A Dyslexia Intervention Connecting Teacher, Avatar & Student (2nd Grade +)
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3:00 PM - 4:00 PM
4:00 PM - 5:00 PM
5:00 PM - 6:00 PM
6:00 PM - 7:00 PM
Student Name
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First Name
Middle Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
N/A
Current School
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Address
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Address
Street Address Line 2
City
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State
Zip Code
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Parent/Guardian(s)
Name
*
First Name
Last Name
Email
*
Day Phone
*
Cell Phone
*
Name
First Name
Last Name
Email
Day Phone
Cell Phone
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Authorized Pick Ups
Name
Phone Number
Relationship
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Relationship
Name
Phone Number
Relationship
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Emergency
Physician Name
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Hospital Name
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AR
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CA
CO
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DE
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GA
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ID
IL
IN
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KY
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ME
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MA
MI
MN
MS
MO
MT
NE
NV
NH
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NY
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OR
PA
RI
SC
SD
TN
TX
UT
VT
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Allergies
Medication Allergies
Food Allergies
Other Allergies
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Checkout
Registration Details
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Registration/Enrollment Fee
$
500.00
Supply Fee
$
1,000.00
Credit Card Details
First Name
Last Name
Credit Card Number
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Card Expiration
Parent/Guardian Signature
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Date
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Month
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Day
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Date
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