Sinkinson Dyslexia Foundation Intake Form

Sinkinson Dyslexia Foundation Form
Guardian 1 First Name *
Guardian 1 Last Name *
Guardian 1 Middle Initial
Guardian 1 Cell Phone
Guardian 1 Work Phone
Guardian 1 e-mail
Guardian 2 First Name
Guardian 2 Last Name
Guardian 2 Middle Initial
Guardian 2 Cell Phone
Guardian 2 Work Phone
Guardian 2 e-mail
Total Income
Household Size
Child First Name *
Child Last Name *
Child Middle Initial
School Name *
Age *
Grade *
Gender *
Street Address *
Apartment Number
City *
State *
Zip-code *
Please explain your concerns for your child as well as why you feel they could be struggling due to the reading order dyslexia. *

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