PARENT Contact Information for Blank Canvas Awareness Art
We want to provide you with the best resources and this information will help us know what you are looking for and to help with communication in the future. We will not sell your information to anyone, and it is confidential.
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Date  *
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Primary Parent Contact Name *
Email *
Phone number *
Mailing Address
Additional Parent Contact Name
I have more than 1 student
Student 1 Name *
Student 1 DOB
Student 1 Current Grade *
Student 1 Name of School
 Student 1 Type of School
Student 1 Diagnosis
Student 1 Other Concerns and Information:
Student 2 Name
Student 2 DOB
Student 2 Current Grade
Student 2 Name of School
 Student 2 Type of School
Student 2 Diagnosis
Student 2 Other Concerns and Information:
Student 3 Name
Student 3 DOB
Student 3 Current Grade
Student 3 Name of School
 Student 3 Type of School
Student 2 Diagnosis
Student 3 Other Concerns and Information:
Who Referred you?
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Tell us how we can assist you. Do you need referrals to specialized tutoring, help advocating in the school or what to learn more tips to help with dyslexia and ADHD? Maybe it is something else... *
Make a donation. Blank Canvas Awareness Art is a nonprofit providing support to individuals with learning differences, such as dyslexia and ADHD. We appreciate your donation so we can continue to support literacy in our community with the best practices. https://www.paypal.com/donate?token=PIYE3p_zcazL7bucU7oAn3WRlL6R9winHmQr09EMuDXKr3q-Umn6KDnPjowaRcr-m_ad__W7cLvChGJK
I am interested in participating in Blank Canvas Awareness Art
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I would like monthly updates.
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Internal Notes Only....
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