Reading Clinic Application Form Parent/Guardian Name Parent/Guardian Email Address City Zip Child's Name Child's DOB Has your child repeated a grade? YesNo If yes, which grade? Has your child ever received a psychological evaluation? (i.e. reading disability) YesNo If the above response is yes, we will ask that you bring a copy of the most up-to-date testing. Has your child been diagnosed as having a reading disability? YesNo If yes, was your child referred for special services such as Special instruction in the classroomSpecial education servicesTutoring provided in schoolTutoring by a private tutor or reading clinic Does your child have an IEP? YesNo If yes, what was recommended? Approximately, how many hours does your child spend on homework each night? Does your child require you to sit with them to complete their work? YesNo Does your child read for pleasure? YesNo Does your child enjoy listening to stories read by others (parents, relatives, siblings, etc.)? YesNo How does your child learn best? What do you see as your child’s strengths in school? What do you see as your child’s greatest struggle in school? Do you agree to allow agents of the STAR Center Inc. to administer a reading achievement test to your child to properly determine the strengths and weakness of your child’s reading skills? YesNo Please leave this field empty. Δ
