Your name: -- title -- Mr. Mrs. Ms. Miss Dr.

Street address:

City: ,  State:   -- select --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutD.C.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowa KansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming   Zip:

Email address:

Home phone: Daytime phone:

Please contact me by (check all that apply):
email home phone daytime phone please don't contact me at this time

I am:
the parent of a child with a learning disability
a psychologist or other professional who refers children
a teacher or other professional interested in learning about open positions
other: please specify

If you are the parent of a child with a learning disability:

What programs and services are you interested in for your child?
school year after-school tutoring summer program

If you decide to send your child to the Academy, when do you anticipate you would want your child to begin? -- select -- As soon as possible Spring 2008 Summer 2008 Fall 2008 Summer 2009 Fall 2009 Don't know

Do you have more than one child with learning disabilities? Yes No

Please tell us about your child. If you have more than one child who might attend the Academy In Manayunk, please choose one of them to tell us about:

Child's Name: Age:

What school does your child currently attend?

Current grade: -- please select -- pre-school K 1 2 3 4 5 6 7 8 9 10 11 12

Please tell us about your child's learning disability:

Please tell us what kind of academic program you are seeking for your child:

How did you hear about us?

Additional comments: