Enrollment Form

First Name *

Last Name *

Phone *

Email *

Number of Children Participating in Program: *

Student's Full Name *

If there is more than one child, please the child(ren)'s full legal names here:

Student's Information

Student's Age *

Student's Grade Level *

What is your child's current reading level? *

Is your child homeschooled? *

Has your child previously received educational intervention or tutoring?:

If yes, please describe (Response optional):

Enrollment Type

I'm enrolling as a: *

Your selection helps us provide the right support for you. As our communities are developed, you may be invited to our Parent Support Group or Educators Support Group based on your enrollment type.

Organization & School Enrollments:

If you are enrolling on behalf of an organization or school, a group license is required. Please contact Dyslexia Rescue® administration before purchasing.

I certify that I have full legal authority to enroll the child(ren) in this program. I acknowledge that I have read and agree to the Dyslexia Rescue Terms of Use and Privacy Policy. I also consent to receive communications from Dyslexia Rescue regarding this application and related services.