NYU Steinhardt Literacy Clinic - Parent's Application

Page One

We would like to know what you think your child's reading strengths and needs are so we can use the information in beginning to tutor him or her. Please answer the following questions. As soon as we receive both the parent and the teacher application forms your child will be placed on our list for consideration.

1. Child's Contact Information:

First Name

Last Name

Street Address

Apt/Suite/Office

City

State

Zip

2. Child's Birthdate

calendar

3. Sex

5. Parent's Names

Mother

Father

Other

6. Home Language

7. Which parent should be contacted during the day to schedule an appointment or for questions?

8. Parent's contact information

Email Address

Daytime Phone Number

Eventing Phone Number

Mobile Phone

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