Name:
E-Mail:
Address:
City/State:
Zip Code
Home Phone:
Bus Phone:
Age:
Birthday:
Gender:
Male
Female
Grade:
Public School :
Yes
No
Home School :
Private School :
School Address:
Name of consenting parent if minor:
Previously tested for Dyslexia?
Signs of hyper-activity?
If yes, any drugs or treatment?
Have you read The Gift of Dyslexia, by Ronald D. Davis?
or email: janaleeb_remove_@_remove_dyslexiamentor.com
