Literacy Intervention - Enrollment Form

Thank you for filling out this form to help us complete your set-up for Literacy Intervention.

Parent First Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student First Name

Birthday

YYYY

School

Grade

Date one of the following was received (dyslexia diagnosis, SLD, WIST, screener)

Please email copy to Lisa@inwdyslexia.org so specialist can support your student further

YYYY

Client Agreement

Payment for each week's sessions will be invoiced at the end of the week and processed through debit/credit card via Quickbooks. We ask you pay your bill as soon as it is received. If missed or late payments become the norm you will be removed from the schedule and added back onto the waitlist. I understand the INW Dyslexia Alliance has set aside specific times for my student and prepared for the session accordingly. In the event of a cancellation, I commit to providing a 24-hour notice to my Literacy Specialist or agreeing to cover the session cost. I am aware that repeated cancellations may lead to the possibility of losing my scheduled slot, requiring me to re-enroll to resume participation in Literacy Intervention through the Alliance (assuming there is an opening). If you have read, understand, and agree to all of the above statements - your name in the box below will serve as your signature: (If the client is a minor, please sign as the parent/guardian)

We’re always accepting donations…

When you give to the INW Dyslexia Alliance, you are making an investment in the life of a struggling reader. Your gift, no matter the size, not only positively impacts a student’s educational journey, but helps them thrive in all areas of life!

Help us continue our efforts and change more lives by making a tax-deductible gift today.

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Literacy Intervention - Enrollment Form

We’re always accepting donations…

Welcome! We’re glad you found us!