STUDENT REGISTRATION
Student’s Name: ___________________________________________
Student's Date of Birth ____________________________________
Parent Contact: ___________________________________________
Address: ___________________________________________________
City: _________________________ Zip: _________________________
Home Phone: (____) _____________ Cell: (____) ________________
E-mail Address: ____________________________________________
Emergency Contact: name: ________________________________
phone: ______________________________
School: _______________________
List any food/insect allergies: _______________________
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _
Please contact me about tutoring _____ times per week.
Preferred Day(s): ________________________________
Preferred Time(s): ________________________________
I am interested in a program that addresses:
_____ decoding words, beginning sentence reading
_____ continued decoding combined with sight words,
spelling, beginning fluency
_____ comprehension and fluency
_____ mathematics
“No-Shows” will be charged the $70 session fee
Print and return completed forms to:
The Reading Ladies, 832 S. Lincoln, Hinsdale, Il. 60521
