FDLC Tutoring Application Form

1
Parent/Guardian Name* This field is required.
First Name
Middle Name
Last Name
2
Parent Email* This field is required.
example@example.com
3
Parent Phone* This field is required.
Please enter a valid phone number.
4
Student Name* This field is required.
First Name
Middle Name
Last Name
5
Student Date of Birth* This field is required.
Date
Year
Month
Day
6
Student Grade* This field is required.
Please Select
Please Select
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
7
Academic Status* This field is required.
Please Select
Please Select
Diagnosed Dyslexia or SLD (specific learning disability in reading and or writing)
Struggling in Reading (per teacher, but no diagnosis)
8
Report Card* This field is required.Must show CONDUCT and READING grades for most recent semester.
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Max. file size: 10.0MB
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9
Teacher note of perceived grade level currently reading on or recent testing with estimated reading grade level* This field is required.
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Max. file size: 10.0MB
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10
Psychoeducational Evaluation (if available)
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Max. file size: 10.0MB
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11
Upload Writing Sample OPTIONAL BUT STRONGLY ENCOURAGED Example: dictation sentence Paragraph writing sample (This helps with faster and more accurate group placement)
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Max. file size: 10.0MB
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12
Location Preferred* This field is required.
Please Select
Please Select
Nocatee Location- 425 Town Plaza Ave, Ponte Vedra Beach, FL 32081
Beaches Location - 408 4th St N, Jacksonville Beach, FL 32250
Avondale Location - 2720 Park Street, Jacksonville FL 32205
DePaul School Location - 9750 Deer Lake Court 32246
13
Willing to Attend an Alternate Location if Needed?* This field is required.
Avondale Location - 2720 Park Street, Jacksonville FL 32205
DePaul School - 9750 Deer Lake Court 32246
Beaches Location - 408 4th St N, Jacksonville Beach, FL 32250
Nocatee Location - 425 Town Plaza Ave, Ponte Vedra Beach, FL 32081
No
14
Please Review the ScheduleThe Florida Dyslexia Literacy Center (“FDLC”) offers an intensive dyslexia reading program under which students receive 64 sessions of Orton-Gillingham-based multisensory reading instruction in a small group of four or fewer students. Sessions are 50 minutes in length and will be held twice each week of the school year (Monday and Wednesday or Tuesday and Thursday). The total fee for the year-long intensive program is $6,248, with a $588 deposit required to secure your child’s place. A payment of $3,400 is due August 1, 2026 and a payment of $2,260 is due December 1, 2026. If a student enrolls after the program begins, FDLC will work with the family to calculate a pro-rated tuition.
15
Select Schedule* This field is required.Enrollment options are Monday/Wednesday OR Tuesday/Thursday
Monday/Wednesday Schedule
Tuesday/Thursday Schedule
16
Tuition Commitment Clarity* This field is required.If accepted, families must complete enrollment within 24 hours by paying the non-refundable deposit to secure placement.
I understand this is an August–May program commitment.
I understand tuition is paid in three installments for the 64 sessions.
To secure your spot, you simply pay for the first 6 sessions (3 weeks). THIS IS A NON-REFUNDABLE DEPOSIT of $588 that is applied toward tutoring fees. (THIS WILL NOT BE CHARGED UNTIL THE PARENT SIGNS A CONTRACT UPON STUDENT ACCEPTANCE.)
The second installment of $3400 is due by August 1st. The third installment of $2,260 is due December 1st.
Fees charged by merchants to process payments are the responsibility of the consumer.
Students who join later in the year will be pro-rated to $98 per session, at two sessions per week, with the first 6 weeks due at registration.
I understand that when accepted, I will have 24 hours to enroll by paying the NONREFUNDABLE deposit of $588. This will be applied toward the intervention sessions.
I understand there are NO MAKE UP SESSIONS. Missed sessions, for ANY reason, are non-refundable and cannot be rescheduled.
I understand my child will be required to attend a 30-minute in-person screening to ensure they are placed in their most appropriate Orton Gillingham level. This will take place at your tutoring location the last week of July and the first week of August.
I understand group size is typically 4 like-needed students with one interventionist. Each student will work with 1 or 2 Orton Gillingham trained professionals.
I understand my child will be place in a leveled group during ONE of the following time frames, and this is not selectable by the parent. 4:05 - 4:55; 5:05 - 5:55; 6:05 - 6:55; 7:05 - 7:55
I understand programs are contingent on enrollment and may not run if enrollment is not met. ALL FUNDS WILL BE RETURNED IN THAT UNLIKELY INSTANCE.
17
Screening and Placement* This field is required.Students must attend a 30-minute screening assessment in July before FDLC makes placement decisions. FDLC retains sole discretion over the student’s group placement, instructor, and curriculum pacing. When FDLC contacts the parent to offer the student a placement, within 24 hours the parent must (a) pay the non-refundable deposit of $588.00; and (b) provide a signed, initialed Parent Enrollment Agreement to reserve the student’s place. Submission of an application does not guarantee placement.
Emergency Contact Name
Emergency Contact Phone Number
Relationship to the Student
Medical Information
18
Parent/Guardian Signature* This field is required.
19
Form Submit Date
Date
Year
Month
Day
20
Tuition / Program Fee Payment* This field is required.
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