Learning Center Interest Form

Learning Center Interest Application

Applicant's First Name:

Applicant's Middle Initial:

Applicant's Last Name:

Parent's First Name:

Parent's Last Name

Parent's Phone Number:

Parent's Email Address

Mailing Address:

Birth Date

Gender:

School Presently Attending:

Grade Applying For:

Diagnosed Disability:

Date of First Diagnosis:

Date of Most Recent Testing (must be within last 3 years):

Where was testing conducted?

Names of Tests Administered:

Name(s) of Doctor(s)/Examiner(s):

Does student currently have accommodations from an IEP or 504 Plan?

Does your child take medication? If so, name and dosage of medication:

Is your child diagnosed with ADD/ADHD?

Types of accommodations needed (check all that apply):

Free Text

Please provide copies of all educational neuropsychological, psychological, speech language, and/or psychiatric evaluations to admissions@cranioklepty.com.

I understand that if accepted, I will keep my child's testing current (within 3 years) or I may be dismissed from the Learning Resource Center:

I understand and accept

I do not accept

St. Vincent Pallotti High School

113 St Mary's Pl, Laurel, MD 20707, United States of America

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