Student Information

    First Name:

    Surname:

    Preferred Name:

    Gender:
    MaleFemale

    Child's Date of Birth (Day - Month - Year)

    Child's Current School

    Contact Information

    Person Enquiring

    Relationship to Student

    Email

    Home Number

    Cell Number

    Address

    Address Line 1

    Address Line 2

    Province

    City

    Post Code

    Parent / Guardian Information

    Prefix eg Mr, Mrs, Ms

    First Name

    Surname

    Relationship to Student

    Email

    Additional Information

    Does your child have a current (within 2 years) Psycho Educational Assessment?
    YesNo

    When did you first become aware of your child´s learning barriers?

    What is your child’s primary difficulty at present school

    Entering Year

    Entering Grade

    Would you like a tour?
    YesNo

    I consent to a credit check
    YesNo