Summer Planning Form 2026

1
Parent/Guardian Name* This field is required. We’ll use this to connect with you about scheduling.
2
Email Address* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Student Full Name* This field is required.
First Name
Last Name
6
Student's Birthdate
7
Student Grade* This field is required.Entering Fall 2026
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
8
Student's School
9
What would you like support with this summer?Select the areas that you would like your specialist to focus on this summer.
Reading (including Orton-Gillingham)
Math
Writing
Executive Functions
Speech/Language
I'm not sure yet.
10
EvaluationsPlease share academic, psycho-educational, or speech/language evaluations that will be helpful.
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Max. file size: 10.6MB
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11
Anything you’d like us to know about your learner?Optional—share anything helpful for us to know.
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Ok
Ok
12
Which days typically work best?You will select your most preferred day and times. We will do our best to honor your request. We will confirm your child's schedule approximately 3 days after receiving this request. If we cannot place your child, we will refund any payment we receive.
Monday
Tuesday
Wednesday
Thursday
Friday
13
Time of Day👉 Preferred time of day. You will select your most preferred day and times. We will do our best to honor your request. We will confirm your child's schedule approximately 3 days after receiving this request. If we cannot place your child, we will refund any payment we receive.
Morning (8:00-12:00)
Midday (12:00-3:00)
Afternoon (3:00-6:00)
14
How many sessions per week?We are flexible over the summer. We will work around camps, vacations, etc. Sessions are typically 1-hour.
One Time
More than Two Times
Two Times
Not sure
15
Are you interested in continuing services during the school year?
Yes
No
Not sure
16
Conflicts👉 Any known conflicts? (vacations, camps, etc.)
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Ok
Ok
17
Anything else?Use this space to tell us any additional thoughts about your child, scheduling, or questions you may have.
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Small
Ok
Ok
18
Where would you prefer sessions to take place?
Engage the Brain office
Virtual
Hybrid (office/virtual)
Not sure
19
How would you like to secure your learner’s summer spot?You will select your most preferred day and times. We will do our best to honor your request. We will confirm your child's schedule approximately 3 days after receiving this request. If we cannot place your child, we will refund any payment we receive. Please note: To avoid a disruption in services, we require a credit card on file. Payment information below will not save for future sessions/packages.
10-Hour Pack (Most Popular – Save 10%) — $1,035
Deposit — $230 (applied to first sessions)
Step Up for Students: continue without payment today
20
Step Up for Students – Required Acknowledgements* This field is required.Please call the office 407-636-9281 with credit card information.
I will allocate funds in my EMA account for Engage the Brain prior to scheduling.
I understand a credit card on file is required before services begin.
I understand that if EMA funds are not allocated to Engage the Brain prior to services, Engage the Brain will charge the credit card on file. It is the family's responsibility to make sure there are funds allocated in a timely manner. Engage the Brain will provide a receipt so the family can seek reimbursement from EMA. No credit card refunds will be issued.
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