JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Read-UP+ Interest
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Parent Name
*
Your answer
Phone Number (When is the best time to reach you by phone)
*
Your answer
Child's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Current Grade
*
Choose
3
4
5
6
7
8
Does your child have a diagnosis from a medical professional?
*
LD
ADHD
Not diagnosed
Other
Include additional information you would like to share with LDA-LR. (We are receiving an unprecedented number of applications. We will contact you as soon as we can.)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
