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* 1. Student's Full Name

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* 2. Name of Parent or Guardian completing form

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* 3. Student's Date of Birth

Date

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* 4. Student's Age

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* 5. Student's Grade

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* 6. Student's School

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* 7. County of Residence

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* 8. School District

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* 9. Has the Student Ever been Retained?

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* 10. If Student was retained, what was the reason given?

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* 11. Has the Student ever been diagnosed with a specific learning disorder?

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* 12. If the Student has been diagnosed with a specific learning disorder, which disorder?

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* 13. Does Student have an active IEP?

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* 14. If Student does not have an active IEP, have you requested one from the Student's current school?

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* 15. Does the Student have an active 504?

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* 16. If Student does not have an active 504, have you requested one from the Student's current school?

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* 17. What would you like help with? (Check all that apply)

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* 18. What is your primary contact number?

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* 19. What is your email address?

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* 20. What is your physical address?

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* 21. What is the best way to reach you?

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