• Idam-Learning DisabilitiesAssociation of ManitobaTutoring Program Intake Form

  • Thank you for your interest in tutoring services with the Learning Disabilities Association of Manitoba (LDAM).

    Please complete the form below so we can better understand your needs. All information will be kept confidential and used only for program planning and communication. Once this form is submitted, you will be placed on our waitlist for services.

  • What tutoring services are you interested in?

  • What tutoring services are you interested in?

  • Where would you like to access tutoring services?

  • Where would you like to access tutoring services?

  • Account Holder Information

  • Format: (000) 000-0000.

  • Communication Preferences

  • Preferred Contact Method:

  • Student Information

  • Date of Birth (MM/DD/YYYY):
     - -
    2 digit month, 2 digit day, 4 digit year

  • Student's Learning Profile

  • 4. Is there an adapted learning plan in place at school?

  • 5. Current Support Services:

  • 6. If you are enrolling in our Barton program, has the student participated in Barton Tutoring elsewhere?

  • Billing & Payment

  • A valid credit card is required on file for all accounts, regardless of payment method (see Tutoring Policies, Section 2 - Payment & Balances). Credit card information will be collected securely during your intake meeting with our Admin Coordinator, which will be scheduled after this form is submitted.
  • Would you like to set up a monthly payment plan for tutoring services?

  • Additional Information

  • Signature & Confirmation

  • By signing below, I confirm that:
    • I confirm that I have the legal authority to enroll this child in LDAM programs, and that this enrollment does not violate any custody agreement or court order currently in place.
    • The information I have provided is accurate and complete.
    • I have read and agree to the Tutoring Policies, including Sections 2 (Payment & Balances) and 3 (Cancellations).
    • I consent to receiving tutoring services and program communication from LDAM.
    • I understand that a valid credit card must be provided and kept on file for my account, regardless of payment method. Credit card information will be collected securely during the intake process.
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Next Steps:

    1. Submit this form to us by:
      • Email: admin@ldamanitoba.org
      • Mail: LDAM, 609 Erin Street, Winnipeg, MB R3G 2W1
      • In Person: Drop it off at our Administrative Office (address above)
    2. Our team will review your information.
    3. We will contact you to schedule your intake appointment.
  • If you have any questions, or need help completing the form,
    please contact us at 204-774-1821 ext. 3 or email admin@ldamanitoba.org. We're happy to assist you!

  • Office Use Only (LDAM Staff)

  • MM/DD/YYYY
     - -
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: