Community HELP Application

Application for Community HELP Students

Name(Required)

First Last

Date of Birth(Required)

School

Year of School

Check Box if Home Schooled

Parent/Guradian Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Parent/Guradian Name (opt)

First Last

Phone Number

Date of last pscyhoeducation evaluation (if applicable):

Please check the diagnosis(es) you have received that makes you eligible for our services:(Required)

Specific Learning Disability (dyslexia, dysgraphia, dyscalculia)

Attention Deficit Hyperactivity Disorder

I have not received any of the above diagnoses

Please list any additional diagnoses:

Please explain why you are seeking academic tutoring services (reading, writing, spelling, mathematics; please be as specific as possible).(Required)

Please check your preference of contact:(Required)

I would like to receive a phone call regarding my application.

I would like to receive an email regarding my application.

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