DYSLEXIA PHILOSOPHY ACADEMICS EVALUATION CENTER ADMISSIONS APPLICATION FINANCIAL INFORMATION FINANCIAL AID PARENT INFORMATION
CLICK HERE FOR THE APPLICATION IN PDF FORMAT FOR PRINTING
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______________________________
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 FINANCIAL AID PARENT INFORMATION