Summer Reading Academy Registration

Summer Reading Academy

Registration Form
Thank you for registering for our Summer Reading Academy at Nelms Dyslexia Center. We are excited to have you with us!

We want every child in our Summer Reading Academy to receive instruction that meets their unique learning needs. As part of the registration process, we ask parents to share specific information about their child’s reading history, strengths, and areas of need. This information helps us thoughtfully group students and tailor instruction so each child is supported, challenged appropriately, and set up for success in a small-group learning environment.

Please feel free to call us with any questions you may have at 479-313-6007.
Student First Name*
Student Last Name*
Students Age*
Students Grade*
Student Date of Birth*

MonthDayYear
Date
Student School*
Parent(s) Name*
Parent Contact Phone*
Parent Contact Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you registering this student with a sibling?

YesNo
Please identify difficulties your student is having, or has had in the past:

Mixes up sounds or syllables in longer words, like pasghettiDelayed speechDifficulty memorizing things like the alphabet, phone number, or days of the week.Slow, dark, messy, or. non-automatic handwritingLetter or number reversals past the end of first gradeDifficulty with spellingSlow, choppy, inaccurate readingLeaves out small words, like prepositions, when readingReads a word on one page, but doesn't recognize it on the next pageDifficulty with written expressionDifficulty with organization and time managementOther
Please describe any literacy difficulties that were not listed:
Do you have immediate or extended family members with dyslexia or undiagnosed reading or learning difficulties? If yes, please describe:
Please describe any intervention your student has received at school or outside of school for learning difficulties.
Does your child have any diagnosed or suspected medical conditions?

Autism Spectrum DisorderIntellectual DisabilityDevelopmental Language DelayADHDAnxiety/DepressionOther
Please describe any behavioral difficulties your child has experienced:
Each child responds to instruction differently and outcomes may be different than anticipated. Nelms Dyslexia Center and staff are not liable for students lack of progress or achievement. Nelms Dyslexia Center therapists are committed to performing all duties and responsibilities pertaining to the programs with fidelity and with the intent to increase student's academic performance and literacy achievement.

There are cameras throughout the center and in each therapy room for safety of students and center staff.

If a child's behavior becomes disruptive or concerning, we will discuss with parents and work collaboratively to address the concern to the best of our ability. If disruptive behavior persists and the child is not able to participate and benefit from instruction, a student may be released from services at the Nelms Dyslexia Center.
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Session Selection

Please select the session(s) your student will attend. If your student will attend both sessions, select one option for Session 1 and one option for Session 2.
Selections*
prevnext( X )
Session 1: June 1st - June 12th 10:00 a.m. - 12:00 p.m.
$800.00



Session 1: June 1st - June 12th 2:00 p.m. - 4:00 p.m.
$800.00



Session 2: June 15th - June 26th 10:00 a.m. - 12:00 p.m.
$800.00



Session 2: June 15th - June 26th 22:00 p.m. - 4:00 p.m.
$800.00



Total

$0.00
Payment

You will receive an invoice 1-2 days after submitting registration. Any applicable sibling discount will be applied to the invoice.
How will you be paying?*

Literacy Grant (enter Grant ID number below)Private Pay
If you are using the Arkansas Literacy Grant, you must enter your Arkansas State ID Number, which can be found on your grant letter.
Should be Empty:

Summer Reading Academy

Session Selection

Payment