Student's Full Name *

First Name

Last Name

Student's Date of Birth *

MM

DD

YYYY

Student's Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact *

First Name

Last Name

Primary Contact Phone Number *

(###)

###

####

Parent's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does your child have an IEP? *

Yes

No

Father's Employment Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Employment Business Phone

(###)

###

####

Mother's Employment Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Business Phone

(###)

###

####

Person Responsible for Tuition Payments *

First Name

Last Name

Person Responsible for Tuition Payment Phone *

(###)

###

####

NONDISCRIMINATION POLICY

Lighthouse Academy for Dyslexia is an equal opportunity employer and educational institution. The school does not discriminate in employment or in enrollment. The Lighthouse Academy for Dyslexia admits students of any race, color, national and ethnic origin to all the rights, privileges, programs, and activities generally accorded or made available to students at the school. It does not discriminate on the basis of race, color, national and ethnic origin in administration of its educational policies, admissions policies, and athletic and other school-administered programs.

I Understand