DYSLEXIA PHILOSOPHY ACADEMICS EVALUATION CENTER ADMISSIONS APPLICATION FINANCIAL INFORMATION
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_______________________________
Fraternal 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
120 South George Avenue, Petal, MS 39465
601-297-2362
DYSLEXIA PHILOSOPHY ACADEMICS EVALUATION CENTER ADMISSIONS APPLICATION FINANCIAL INFORMATION