Hope Academy for Dyslexia Interest Form
Parent Name
*
Parent email address
*
Parent phone number
*
What is the best way to reach you?
*
Phone
Email
Text
What is the best time to reach you?
Before 10:00 AM
Between 10:00 AM and 2:00 PM
After 2:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday
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Student Information
Student Name:
*
Student grade level
*
Please Select
1st
2nd
3rd
4th
5th
6th
Has your student been diagnosed with dyslexia?
*
Yes
No
If yes, when was this diagnosis made?
Please submit the student's Diagnostic Evaluation if available.
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Has your child previously received therapy for dyslexia?
*
Yes
No
If so, where?
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