Reading & Writing Summer Program Service Selected:Reading & Writing Summer ProgramChoose summer session----Summer Session 1Summer Session 2Signing up as:*I am a parent signing up my childI am a student, 18 years of age and above, and will be signing up as myselfParent Name* First Last Email* Phone Number*Students Name* First Last Grade Level*--- Select ---K-Pre School1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeUndergraduateGraduateAdultDoes your student have any learning disabilities?----YesNoLearning Disabilities Diagnosed ADHD ADD Dyslexia Dyscalculia Dysgraphia Dyspraxia Autism (Average IQ) Autism (Below Average IQ) None Other Upload Formal Testing DocumentationSchool / Campus Name*How did you hear about us?*--- Select ---FriendFamilyGoogleBingYahooFlyerSchoolTeacherWalk-inOtherWho? Name if possible:*Name of School:*Name of Teacher & Class:*To better help us. What did you type in?*Additional Info:*Enrollment Fee----Regular Enrollment FeeLate Enrollment FeeN/A Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Expiration Date Security Code Cardholder Name Office Notes (Office Use Only)