Leap Learning Waitlist

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All information gathered is strictly confidential and will not be shared with any outside parties. Once we receive this form, we will contact you to discuss scheduling options.

Email *

First and last name of person making request *

Phone number *

First and last name of student (if different from above) *

Please tell us more about the student *

K-6 student

7-12 student

Adult

Required

Does the student currently have a diagnosed learning disability? *

Yes

Required

If yes, please give details

What service is your priority? *

Formative Assessment

Orton-Gillingham Literacy Intervention

Targeted Writing Instruction

Homeschool Support

Other:

Required

What frequency of sessions can you commit to? *

Intervention: regular lessons, twice a week (Priority is given to these clients)

Regular lessons, once a week

One-Time Formative Assessment

Required

Please outline the student's availability for online lessons. *

Please be as specific as possible including days of the week and times of day. Please understand that outside of school hours are limited and will therefore have longer wait times.

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