Hillside School Inquiry Form
Primary Parent Information
Parent/Guardian Salutation
Please select...
Mr.
Mrs.
Ms.
Dr.
Prof.
Parent/Guardian First Name
Parent/Guardian Last Name
Primary Parent/Guardian Relationship
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Mother
Father
Guardian
Aunt
Cousin
Friend
Grandfather
Grandmother
Grandparent
Sibling
Uncle
Parent/Guardian Email
Email Type
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Personal
Work
Family Email
Parent/Guardian Phone
Phone Type
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Mobile
Home
Office
Street Address
City
State/Province Code
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
Zip Code
Country
Secondary Parent/Guardian Information
Parent/Guardian #2 Salutation
Please select...
Mr.
Mrs.
Ms.
Dr.
Prof.
Parent/Guardian #2 First Name
Parent/Guardian #2 Last Name
Secondary Parent/Guardian Relationship
Please select...
Mother
Father
Guardian
Aunt
Cousin
Friend
Grandfather
Grandmother
Grandparent
Sibling
Uncle
Child Information
Child's First Name
Child's Last Name
Date of Birth
Child's Age
Child's Gender
Please select...
Male
Female
Other
Child Lives with Both Parents?
Yes
No
Current School Name
Current School Grade
Please select...
Pre Kindergarten
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Ninth Grade
Tenth Grade
Eleventh Grade
Twelfth Grade
Educational Concerns
(Please check all that apply)
Difficulty with Abstract Concepts
Difficulty with Arithmetic
Difficulty with Expressive Language
Difficulty with Handwriting
Difficulty with Maintaining Attention
Difficulty with Math Fluency
Difficulty with Organization
Difficulty with Reading
Difficulty with Reading Fluency
Difficulty with Receptive Language
Difficulty with School Attendance
Difficulty with Spelling
Difficulty with Writing Fluency
Difficulty with Written Language
If your child has had educational or psychological testing done, please summarize the findings here:
Date of Evaluation
Name of Evaluator
Please briefly explain the difficulty your child is having in school:
Please select the Hillside Program for which you are interested in receiving information
Please select...
School Year 2023-24
Summer 2023
School Year 2024-25
Other
Hillside sponsors a monthly forum called HillTOPICS about issues related to learning differences. Would you like to receive notice of these meetings and other Hillside news?
Yes
No
Do you want information on our summer programs?
Yes
No
How did you hear about Hillside?
Please select...
Web Search
Social Media
Advertisement
Event
Professional reference
Personal reference
Other
If "Other" Selected, please explain:
Send Inquiry to:
Contact Information