Learning Center Interest Form

Learning Center Interest Application

Applicant's First Name:

Applicant's Middle Initial:

Applicant's Last Name:

Home Phone:

Birth Date

Gender:

Mailing Address:

School Presently Attending:

Grade Applying For:

Diagnosed Disability:

Date of First Diagnosis:

Date of Most Recent Testing (must be within last 3 years):

Names of Tests Administered:

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

Verbal Reasoning:

Visual-Spatial/Perceptual Reasoning:

Fluid Reasoning (WISC-V):

Working Memory:

Processing Speed:

Full Scale IQ:

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):

I understand that if accepted, I will keep my child's testing current (within 3 years) or I may be dismissed from the Learning Resource Center:

I understand and accept

I do not accept

St. Vincent Pallotti High School

113 St Mary's Pl, Laurel, MD 20707, United States of America