Student
Which of our locations will your student be attending?
*
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
Please Select
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State
Zip Code
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Parent/Guardian(s)
Name
*
First Name
Last Name
Email
*
Day Phone
*
Format: (000) 000-0000.
Cell Phone
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Format: (000) 000-0000.
Name
First Name
Last Name
Email
Day Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
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Authorized Pick Ups
Name
Phone Number
Format: (000) 000-0000.
Relationship
Name
Phone Number
Format: (000) 000-0000.
Relationship
Name
Phone Number
Format: (000) 000-0000.
Relationship
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Emergency
Physician Name
Phone Number
Format: (000) 000-0000.
Address
State
Please Select
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AK
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CO
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DE
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HI
ID
IL
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ND
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RI
SC
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Zip Code
Hospital Name
Phone Number
Format: (000) 000-0000.
Address
State
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
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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
Security Code
Card Expiration
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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