Connect ~ 2 ~ Learning LLC
Student Record Form - "Get to Know Me"
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PARENT NAME (IF UNDER 18)
CONTACT NUMBER
STUDENT NAME
ADDRESS
STUDENT DATE OF BIRTH
STUDENT SCHOOL GRADE FOR
 2025 - 2026 SCHOOL YEAR
WHERE DOES STUDENT ATTEND SCHOOL?
WHO IS THE STUDENT'S PRIMARY TEACHER?
STUDENT RETENTION? ( Check all that applies)
STUDENT MEDICAL HISTORY AND OTHER PERTINENT INFORMATION (Check all that applies)
FOR ANY AREA ABOVE MARKED WITH A STAR,  PLEASE SHARE MORE SPECIFIC INFORMATION. FOR EXAMPLE, IF YOUR CHILD HAS MEDICAL CONCERNS - PLEASE DESCRIBE. IF THE STUDENT HAS HAD A SURGERY, WHAT TYPE? IF THERE IS A FAMILY HISTORY OF DYLSEXIA, WHAT RELATION TO THE STUDENT?  IF YOUR CHILD HAS BEEN DIAGNOSED WITH A CONDITION NOT SPECIFIED ABOVE, NAME THE CONDITION.  
HOW IS THE STUDENT MOTIVATED ? (check all that applies)
LIST STUDENT INTERESTS AND/OR HOBBIES
LIST STUDENT'S STRENGTHS
LIST STUDENT'S WEAKNESSES
FEEL FREE TO ADD ANY OTHER INFORMATON NOT PREVIOUSLY MENTIONED TO HELP IN GETTING TO KNOW THE STUDENT. 
How did you learn about the Dyslexia Center?
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TODAY'S DATE
THIS INFORMATION  WAS COMPLETED BY 
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