Enrollment Form

ESA Enrollment Form

First Name *

Last Name *

Phone *

Email *

Student's Information

Student's Full Legal Name (matching ESA information) *

Student's Age *

Student's Grade Level *

What is your child's current reading level? *

This student must be currently enrolled in the Arizona ESA program- please confirm *

Has your child previously received educational intervention or tutoring?:

If yes, please describe (Response optional):

I have read the ESA Family Acknowledgement. I understand that Dyslexia Rescue does not guarantee ESA reimbursement, that I submit the reimbursement myself, and that there are no refunds if ESA does not pay me. I agree to these terms.

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.