Dyslexia Services Foundation Scholarship Application

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Applicant Name *

Who is applying for this scholarship (Student Name)?

Parent or Guardian *

If the applicant is a minor please provide the legal guardian's name.

Birthdate & age *

What is the applicant's date of birth and current age?

Grade in school *

What is the applicant's current grade (or the last grade completed)?

Home language *

What language(s) is/are spoken in the applicant's home?

Address *

What is the applicant's home address (full address or city & state)?

Phone *

What is the applicant's /parent's phone number? (If none, write "none".)

email *

What is the applicant's / parent's email address. (If none, write "none".)

Financial need *

What evidence of financial need will the applicant be providing?

Medicaid card

Reduced price school lunch affidavit

Other:

What is the best way for us to contact you? *

phone (number above)

email (address above)

US mail (home address above)

What problems is the applicant experiencing related to their literacy (reading, spelling, writing) skills? *

If the applicant has completed this free screener (free Dyslexia Screener), did they score at risk for dyslexia?

Do you have any questions or is there anything else you'd like us to know about this scholarship application?

Submit

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