Learning Center Interest Form

Applicant's First Name Required

Applicant's Middle Initial

Applicant's Last Name Required

Home Phone Required

Mailing Address

Address 1

Address 2

City

State/Province

Country

Postal Code

Birth Date Required

Gender Required

School Presently Attending Required

Grade Applying For Required

Testing Information

Diagnosed Disability Required

Date of First Diagnosis Required

Date of Most recent Testing (Must be within last three years) Required

Names of Tests Administered

Name(s) of Doctor(s)/Examiner(s)

Cognitive Ability Standard Scores (SS)

Verbal Reasoning

Visual-Spatial/Perceptual Reasoning

Fluid Reasoning (WISC-V)

Working Memory

Processing Speed

Full Scale IQ

Academic Achievement Standard Scores (SS)

Broad Reading

Broad Math

Broad Written Language

Academic Fluency

Does your child take medication? If so, name and dosage of medication

Is your child diagnosed with ADD/ADHD?

Types of accommodations seeking (check all that apply)

Extended time

Reduced written work

Write answers on test/quiz (not scantrons)

Seated in front row

Use of a word processor or grammar and spelling don't count

Extra breaks

Use of a calculator

Copies of notes

Formulas for math and science assessments provided

I understand that if accepted I will keep my child's testing current (within three years) or I may be dismissed from the Learning Resource Center.

Learning Center Interest Form

Testing Information

Cognitive Ability Standard Scores (SS)

Academic Achievement Standard Scores (SS)

PlusPortals Sign In