Learning Disability Therapy Package C | Payment Option 1/6 Service Selected:Package C Learning Disability Therapy $110/session (48 Session Package)(64 Hours) - Payment Option 1/6 - $880 (+$25 Payment Plan Fee)Signing 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 GradeUndergraduateGraduateAdultSchool / Campus's Name*Tutoring Location*--- Select ---Suprex Learning Center Sugar Land: 104 Industrial Blvd, STE Q, Sugar Land, TX 77478Suprex Learning Center Houston: 1121 Delano Street, Houston, TX 77003My HomeMy School / CampusOnlineOtherTutoring Location: Name of Location*Tutoring Location Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Disability:* ADD ADHD Dyslexia Dysgraphia Dyscalculia Dyspraxia Autism Other State other disability:Dates & Times Available and Additional Notes:*Materials* Blue Book Method (Reading) +$25.00 Blue Book Workbook (Reading) +$20.00 Sounds of Language (Reading) +$35.00 Sounds of Speech +$40.00 Chalkboard +$40.00 Chalkholder +$10.00 Student Reference Sheet (Reading) +$25.00 I am a return customer and already have the materials listed above. I do not know which materials are needed, will order after Assessment 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:* Preliminary Price:$880.00 Payment Fee:$25.00Payment 1 of 6: $0.00 Your next 5 recurring payments will be:$905.00Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Expiration Date Security Code Cardholder Name Office Notes (Office Use Only)