Parent First Name:
Parent Last Name:
Phone Number:
Cell Phone Number:
Parent Address:
City:
State:
Zip:
Email:
Child's First Name:
Child's Last Name:
Date of Birth: (mm/dd/yyyy)
Current School:
Current Grade:
Who Recommended Gateway:
Has your child received a psycho-educational or neuro-psychological evaluation within the previous 18 months indicating a language or perceptually based learning disability?:
Briefly describe the difficulties your child is experiencing in school:
