Page 1

Student Information

Student's First Name

Student's Last Name

Student Email (if your student doesn't have an email, please leave this blank)

Student's School Name

Home Street Address

City

State

Zip

Date of Birth

Gender:

Please describe:

Grade Level (select one)

What is your student's race or ethnic background?

American Indian or Alaska Native	Asian or Asian American
Black, African, Caribbean, or African American	Native Hawaiian or Other Pacific Islander
White, Caucasian, Middle Eastern, or North African	Hispanic or Latino
Prefer not to disclose

Is your student eligible for free or reduced-price lunch?

YesNoPrefer not to disclose

How did you hear about Learning Differently 101?

Page 2

Tell us about your student's Learning Difference

What is your student's learning difference?

Note: Eye to Eye is specially designed for students who learn differently, including those identified with ADHD and specific learning disabilities like Dyslexia, Dyscalculia, Dysgraphia, NVLD, and challenges with processing, comprehension, and executive functioning.

ADHD/ADD	Auditory Processing Disorder
Central Auditory Processing Disorder (CAPD)	Dyscalculia
Dysgraphia	Dyslexia
Dyspraxia	Executive Functioning Issues
Math LD	Non Verbal Learning Disability
Processing Disorder	Reading LD
Reading Processing Disorder	Slow Processing Speed
Visual Processing Disorder	Other
Not sure

Please explain your selection of "Other" for your student's learning difference:

When was your student identified has having a learning difference?

Does your student have an IEP or Section 504 plan?

Does your student know that they have a learning difference?

Is there anything else we should know about your student's learning difference?

Page 3

Parent/Guardian Contact Info

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship(s) to Student

Email Address

What is the last type of education you completed?

Contact Information