Full Name________________________________DOB/Age__________________Phone #____________________

Student's Address ______________________________________________________________________________

Father's Name   ________________________________________________ Cell Phone #_____________________

Address (if different)____________________________________________________________________________

Mother's Name ________________________________________________Cell Phone #_____________________

Address (if different) ___________________________________________________________________________

Parent's  e-mail address(s) ______________________________________________________________________

Father's Employment_____________________________________Address_______________________________

Mother's Employment ___________________________________ Address _______________________________

Sibling Names and Ages_________________________________________________________________________

Last School Attended_________________________________________________________Grade_____________

Person Responsible for Tuition Payments__________________________________________________________

Address_______________________________________________________Telephone_______________________

Maternal Grandparents__________________________________________Telephone_______________________

Address_______________________________________________  City/State_______________________________

Paternal Grandparents___________________________________________ Telephone______________________

Address ________________________________________________  City/State______________________________

Most Recent Testing Dates and Location (attach copy)_________________________________________________

Does the student have any allergies__________  If yes, explain_________________________________________

Describe any health problems_____________________________________________________________________

Does the student take an medications (List)_________________________________________________________

Student's Physician:_________________________________________Telephone:__________________________

Health Insurance Information_____________________________________________________________________

Who referred you to the 3D School________________________________________________________________

What was the reason for the referral______________________________________________________________

The nonrefundable application fee of $100.00 should be submitted with the application.

DYNAMIC DYSLEXIA DESIGN / THE 3D SCHOOL