After School Literacy Program: An Orton Gillingham Small Group Experience Application
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Application Fee: A non-refundable fee of $50, must accompany this application.
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$50.00
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Credit Card
Prospecitive Student Name
*
First Name
Last Name
Prospective Student DOB
*
Prospective Student Grade Level & Current School
*
Does your student have a formal diagnosis?
*
Dyslexia
SLD - Specific Language Disorder
ADHD
Dyscalculia
Dysgraphia
None
Other
Please inform us regarding the sequence of your child’s education. Has your child ever:
*
Repeated a grade
Skipped a grade
Missed school for an extended period
Been asked to withdraw from school
Been suspended or put on probation
None
Other
If yes to any of the above, please comment below if you wish:
*
At present, is your child taking any prescription medications?
*
Yes
No
If so, kindly list them (type N/A if not applicable).
*
Has your child displayed behavioral problems in school or at home?
*
Does your child have a history of emotional problems or psychological counseling?
*
Please, upload any testing you have for your child.
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The information provided herein is the sole property of The Bilgrav School and is accurate and contains all information requested. We have neither omitted nor embellished any facts relating to our child’s application. The Bilgrav School reserves the right to amend or withdraw offers of admission due to mitigating circumstances, changes in information, student’s standing or other reason as determined by the Admissions Committee.
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