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Orton-Gillingham Instruction Registration
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* Indicates required question
Parent Contact Information
Parent First Name:
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Your answer
Parent Last Name:
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Your answer
Address (including postal code):
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Your answer
Phone Number:
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Your answer
Email:
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Your answer
Alternate Parent/Guardian/Caregiver - Name, Relationship, and Number:
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Your answer
Emergency Contact - Name, Relationship, and Number (include cell and work number when relevant):
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Your answer
How did you hear about this service?
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Online Search
Word of Mouth
Email
Social Media
Video
Magazine
Newspaper
Chatterblock
Other:
Required
Student Information
Child First Name:
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Your answer
Child Last Name:
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Your answer
Current Grade
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Your answer
Current School
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Your answer
Student Profile
What are the reasons for wishing the applicant to enroll in After3 Orton-Gillingham Language Instruction?
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Your answer
Describe the applicant's academic areas of difficulty with literacy development? (eg. reading, writing, spelling)
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Your answer
Has the applicant received remedial instruction, such as learning assistance or tutoring, either at or outside of his or her current school? If yes, please provide details.
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Your answer
Has your child attended or applied to Fraser Academy before?
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Yes
No
Please select the boxes that apply as to the information you can provide us for creating your child's program:
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Please submit copies of these documents electronically to FAx or hard copies to the school (2294 West 10th Ave) as soon as possible.
Report Cards from the last year
Most recent IEP
Psycho-Educational Assessment
SLP or other therapeutic reports
Required
Instructional Options
We want our lessons to be:
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Face-to-face at Fraser Academy
Remote learning (online)
Desired Start Date
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MM
/
DD
/
YYYY
Admissions Request
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Fall Admission (mid-Sept to mid-Dec)
Winter/Spring Admission (mid-Jan to mid-June)
Full Year (mid-Sept to mid-June)
Days for Service:
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Mondays and Wednesdays
Tuesdays and Thursdays
Required
Preferred Time
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4:00-4:50 pm
5:00-5:50 pm
6:00-6:50 pm
Daytime hours (if possible)
Required
Medical Information
Student's Date of Birth:
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MM
/
DD
/
YYYY
Please indicate any medical information or allergies (if this does not apply, please type "N/A"):
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Your answer
Parent/Guardian Consent:
I understand that photos and media (eg. photos) from After3 may be displayed throughout the school, included in our newsletters/eblasts, posted on our website, placed in online or print ads and/or be used as a part of our faculty evaluations.
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Agree
Disagree
Payment
Please select one of the four payment options.
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I will set up automatic credit card payments via
request.plastiq.com/pay-fraser-academy1
(this option incurs a 2.4% administration fee charged by Plastiq)
I will provide post-dated cheques payable to Fraser Academy
I will pay by Interac e-transfer to the email address
accountspayable@fraseracademy.ca
(no security answer is necessary)
Confirmation
I understand that the fee for After3 Programs at Fraser Academy is non-refundable, and that there will be two make-up sessions per semester for any lessons missed, to be coordinated by your instructor with the student. 24 hours notice is required for cancellation or rescheduling.
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Yes
Required
Signature (type Parent/Guardian Name):
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Your answer
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