Dyslexia School of Houston Microschool Application Form

Dyslexia School of Houston Microschool Application
2026 - 2027 Academic School Year

Thank you for your interest in the Dyslexia School of Houston Microschool. We are honored that you are considering our program for your child.

Our Microschool is designed for students in Kindergarten through 2nd Grade with dyslexia and related learning differences who would benefit from a structured, language-rich, and highly supportive academic environment.

This application is the first step in our admissions process and helps us determine whether our program is the right fit for your child’s unique learning needs.

Please complete the form below and upload any relevant documentation, including educational evaluations and current IEPs (if applicable). A nonrefundable application fee of $75 is required to submit your application.

After submission, our team will review your information and follow up with next steps, which may include additional screening and a campus visit.

If you have any questions during this process, please contact Elizabeth van der Pol,
Director of Microschool, at liz@dyslexiahouston.org.
Student Application
Student Information
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Grade Applying For*
Kindergarten - 2nd Grade
Current School Information
Current School Attending*
N/A if not applicable
YesNo
If yes, how long has your child been homeschooled?
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Work Email Address
Academic & Support Information

Help us understand your child’s learning needs
YesNo
Upload Evaluation and/or Current IEP

Upload the most recent evaluation and any current IEP or 504 plan to help us better understand your child’s needs.
Cancelof
Does your child currently receive any additional therapies (e.g., speech, occupational, etc.)?*
If applicable, please provide details on type and frequency of services.

Nonrefundable Application Fee

Microschool Student Application Fee

$75.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I confirm that the information provided is accurate to the best of my knowledge.
Should be Empty:

Dyslexia School of Houston Microschool Application

2026 - 2027 Academic School Year

Student Application

Student Information

Current School Information

Parent/Guardian Information

Academic & Support Information