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Target Learning Registration Form
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* Indicates required question
Email
*
Your email
Student's name:
*
Your answer
Gender:
*
Female
Male
Required
Date of birth:
*
MM
/
DD
/
YYYY
School:
*
Your answer
Year level:
*
Your answer
Parent/Guardian's name:
*
Your answer
Parent/Guardian's contact number:
*
Your answer
Parent/Guardian's Address:
Your answer
Services Requested (select all that apply):
*
Mathematics Academic Coaching
English Academic Coaching
Mathematics Diagnostic Assessment
English Diagnostic Assessment
Dyslexia Screening
Dyscalculia Screening (Math Dyslexia)
Dyslexia Academic Coaching
Required
List other subject/service requested (if applicable):
Your answer
Time(s) Requested
Please select all the times your child is available.
Saturdays
*
9:30
10:00
10:30
11:00
11:30
12:00
Not available on Saturdays
Required
Wednesdays
*
4:00
4:30
5:00
Not available on Wednesdays
Required
Requested number of sessions per week:
*
1
2
3
4
Required
A copy of your responses will be emailed to the address you provided.
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