Literacy Screening Inquiry

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Everyone Reads PA Literacy Screenings

Our Screening Program is tailored to each individual student. In order to determine the appropriate screeners, we must collect student specific information. Please note that our team are not attorneys and are not providing legal advice or opinions.

After completing this form, an Everyone Reads PA representative will contact you. Should you not hear from us within 2 weeks, please email Kate Murphy at ktamurphy@gmail.com. This program is supported by donations from private individuals.

Email *

Today's Date *

YYYY

Guardian's First Name *

Guardian's Last Name *

Guardian's Address (City, Street, Zip) *

Guardian's Phone Number *

Student Name *

Student's Current Grade *

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Other

Required

Current School *

Current Public School District *

Please check all below that are applicable: * *

Family history of reading difficulties exists (parent, aunt, sibling, etc.)

Concerns were presented at a teacher conference

School benchmark assessments are not at benchmark

School has offered to evaluate for a learning or attention disability

School evaluation of a learning or attention disability has been completed

Private testing for a learning or attention disability is complete

Diagnosis of a learning or attention disability has been received

An IEP (Individualized Education Plan) is in place

A 504 Plan of Accommodations is in place

Requesting professional services resource list (tutors, private evaluators, etc.)*

We would like to be assigned a Everyone Reads PA Literacy Advocate*

We would like our child to participate in Everyone Reads PA Literacy Screenings*

Required

Please provide a brief summary of your child's current situation and the reason for your concerns. If you chose "other" for grade or school above, please include specific information here. *

How did you learn about Everyone Reads PA *

If someone personally referred you to ERPA, please consider sharing their name with us. Thank you!

If you are completing this form on behalf of a student and you are not their parent, please provide your name, email, phone number and mailing address below. Also, please include your relationship to the student (guardian, friend, etc.) Thank you!

Disclaimer - I understand that Everyone Reads PA Literacy Advocates are not attorneys and are not providing legal advice or opinions. * *

Yes

Required

A copy of your responses will be emailed to the address you provided.

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